A nurse is caring for a client with a postoperative wound infection. Which finding indicates the infection is worsening and requires immediate intervention?

Choice A reason: Blood pressure of 94/62 mm Hg indicates hypotension, possibly from hypovolemia or anesthesia, but is less life-threatening than hypoxia. Oxygen saturation of 82% risks organ damage, making blood pressure secondary, requiring fluid or vasopressor support after addressing hypoxia.

Choice B reason: Heart rate of 110 beats/minute (tachycardia) suggests compensation for hypovolemia or pain but is less critical than oxygen saturation of 82%. Hypoxia risks rapid organ damage, while tachycardia is addressed after oxygenation, making it a lower priority in postoperative assessment.

Choice C reason: Oxygen saturation of 82% indicates severe hypoxia, risking brain and organ damage within minutes. Postoperative clients are prone to atelectasis or pulmonary edema, impairing gas exchange. Immediate oxygen therapy or airway management is critical, making this the most urgent finding.

Choice D reason: Urine output of 50 mL/hr is normal (0.5–1 mL/kg/hr), indicating adequate renal perfusion. Unlike oxygen saturation of 82%, which signals critical hypoxia, normal urine output does not require immediate attention, reflecting stable hydration and kidney function.

Choice A reason: Fever and tachycardia indicate systemic inflammation in atelectasis, where collapsed alveoli reduce gas exchange, causing hypoxia. Tachycardia compensates for low oxygen, while cytokines from lung collapse trigger fever. These signs necessitate intervention like incentive spirometry to re-expand lungs, preventing complications such as pneumonia or sepsis, which worsen respiratory distress.

Choice B reason: Productive cough with green sputum suggests a bacterial infection, like pneumonia, rather than atelectasis alone. Atelectasis may predispose to infection by impairing mucociliary clearance, but green sputum indicates a secondary process requiring antibiotics, not primary atelectasis interventions like lung re-expansion, making this choice less urgent.

Choice C reason: Chest pain and increased respiratory rate are critical atelectasis symptoms. Pain arises from pleural irritation due to collapsed lung segments, while tachypnea compensates for hypoxia from reduced alveolar ventilation. These indicate significant respiratory compromise, requiring urgent interventions like chest physiotherapy or deep breathing to restore lung volume.

Choice D reason: Diminished breath sounds and dyspnea are hallmark atelectasis signs, reflecting collapsed alveoli and reduced air entry. Dyspnea results from impaired gas exchange, causing hypoxia and hypercapnia. Immediate interventions like positive pressure ventilation or incentive spirometry are needed to re-expand lungs, preventing further respiratory deterioration and ensuring adequate oxygenation.

Choice E reason: Purulent drainage is not typical of atelectasis but suggests an infectious process like an abscess or empyema. While atelectasis can trap secretions, predisposing to infection, purulent drainage requires specific treatments like antibiotics or drainage, not atelectasis-focused interventions like lung re-expansion, making this an incorrect choice for intervention.