A nurse is collecting data from a client who has heart failure and edema of the lower extremities. Which of the following actions should the nurse take to monitor for pitting edema?

Postoperative clients require close monitoring for early signs of infection, especially within the first few days after surgery when surgical sites are most vulnerable. Infection can develop due to bacterial contamination, impaired tissue healing, or compromised immunity. Common indicators include systemic inflammatory responses such as fever, leukocytosis, and localized signs at the incision site. Nurses must differentiate normal postoperative changes from findings that suggest infection to ensure timely intervention.

Rationale:
A. A temperature of 37.2°C (99.0°F) is within normal or low-grade postoperative range and does not indicate infection. Mild temperature elevations can occur after surgery due to atelectasis or the inflammatory healing process. It is not a reliable indicator of infection on its own.

B. Increased urinary output is not associated with postoperative infection. In fact, infection or sepsis may initially present with decreased urine output due to poor perfusion. Increased output is more likely related to fluid administration or improved renal perfusion.

C. A pain rating of 4/10 is expected in a postoperative client and is not specific for infection. Postoperative pain typically decreases gradually with healing. Infection-related pain is often worsening, localized, and associated with other inflammatory signs rather than a moderate stable pain score.

D. An elevated WBC count is a key indicator of infection because it reflects the body’s immune response to invading pathogens. In a client who is 2 days post abdominal surgery, leukocytosis may suggest developing surgical site infection or intra-abdominal infection. In conditions involving postoperative monitoring such as Postoperative infection, elevated WBCs warrant further assessment and possible intervention.

Postoperative clients require close monitoring for early signs of complications such as infection, bleeding, and impaired wound healing. Surgical site infection typically develops within a few days after surgery and is associated with localized inflammatory changes and systemic responses. Nurses assess wound appearance, drainage characteristics, vital signs, and laboratory values to detect deviations from normal healing. Early identification of infection allows for timely intervention and prevents progression to systemic sepsis.

Rationale:
A. A WBC count of 8,000/mm³ is within the normal range and does not indicate infection. Although elevated white blood cells can suggest infection, this value does not reflect an inflammatory or infectious process. Normal laboratory findings alone do not support postoperative infection.

B. Edema around the incision site may indicate localized inflammation associated with a developing surgical site infection. In Postoperative wound infection, swelling may be accompanied by warmth, redness, pain, and possible purulent drainage. While mild edema can occur normally after surgery, increasing or persistent swelling beyond expected healing patterns suggests infection and requires further assessment.

C. Serous drainage in a closed suction device is expected in the early postoperative period and represents normal healing. Serous fluid is clear or pale yellow and indicates plasma leakage without infection. Infected wounds typically produce purulent, foul-smelling, or cloudy drainage rather than serous fluid.

D. A urine output of 40 mL/hr is within the normal expected range for an adult (generally ≥30 mL/hr). This finding reflects adequate renal perfusion and does not indicate infection. It is unrelated to surgical site infection unless systemic complications develop.