A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

Choice A reason:

The client reports numbness in his right leg. This is not a cause for immediate intervention by the nurse, because numbness is an expected effect of spinal anesthesia. Spinal anesthesia blocks the nerve impulses from the lower extremities, lower abdomen, pelvic, and perineal regions, resulting in loss of sensation and movement.

Choice B reason:

The client has a blood pressure of 90/60 mm Hg. This is not a cause for immediate intervention by the nurse, because mild hypotension is a common side effect of spinal anesthesia. Spinal anesthesia causes vasodilation and decreases the sympathetic tone, leading to reduced blood pressure. The nurse should monitor the client's vital signs and fluid status, and administer vasopressors if needed.

Choice C reason:

The client complains of a headache when sitting up. This is a cause for immediate intervention by the nurse, because it may indicate a post-dural puncture headache (PDPH) PDPH is a complication of spinal anesthesia that occurs when the dura mater is punctured by the needle, causing cerebrospinal fluid (CSF) to leak and create a pressure gradient between the intracranial and spinal compartments. The nurse should assess the client's pain level, position the client flat or with a slight head elevation, administer analgesics and fluids, and notify the anesthesiologist.

Choice D reason:

The client has difficulty voiding after surgery. This is not a cause for immediate intervention by the nurse, because urinary retention is a common problem after spinal anesthesia. Spinal anesthesia affects the bladder function by inhibiting the micturition reflex and impairing the sensation of bladder fullness. The nurse should monitor the client's urine output, bladder distension, and fluid intake, and assist with catheterization if needed.

Choice A reason:

This is the correct answer. This is to prevent the risk of leaving a foreign object inside the patient, which can cause serious complications such as infection, abscess, bowel obstruction, or perforation.

Choice B reason:

This is incorrect. Notifying anesthesia personnel is not the priority action when an incorrect sponge count is reported. Anesthesia personnel are not responsible for counting or searching for sponges, and they cannot intervene in the surgical procedure without the surgeon's consent. The surgeon is the one who needs to be informed first, as they have the authority and ability to search the wound and decide whether to continue or stop the surgery.

Choice C reason:

This is incorrect. Notifying risk management is not the priority action when an incorrect sponge count is reported. Risk management is a department that deals with identifying, assessing, and minimizing potential hazards in health care settings. While it is important to report any adverse events or errors to risk management, this should be done after ensuring the patient's safety and resolving the issue. The priority is to notify the surgeon and search for the missing sponge.

Choice D reason:

This is incorrect. Notifying operating room supervisor is not the priority action when an incorrect sponge count is reported. The operating room supervisor is a person who oversees the daily operations of the surgical suite, such as staffing, scheduling, equipment, and supplies. While they may be involved in addressing any problems or conflicts that arise in the OR, they are not directly responsible for counting or searching for sponges, and they cannot interfere with the surgical procedure without the surgeon's consent. The priority is to notify the surgeon and search for the missing sponge.