A nurse is discussing the components of the working phase of the nurse-client relationship with a client. Which of the following tasks are specific for this stage to create a therapeutic environment?

• Temperature 35.3°C (95.5°F): Hypothermia following surgery is concerning because it may reflect poor perfusion, internal bleeding, or shock. Immediate warming measures and evaluation are necessary to prevent further deterioration.
• Blood pressure 90/60 mm Hg: The client’s blood pressure is lower than previous values and indicates potential hypovolemia or ongoing blood loss. Hypotension post-surgery must be urgently addressed to avoid progression to shock.
• Skin cool and moist to touch: Cool, moist skin is an early clinical sign of decreased tissue perfusion and shock. When found alongside hypotension and hypothermia, it suggests that circulatory compromise may already be developing.
• Moderate amount of sanguineous drainage noted on lower dressing: Moderate bleeding post-laparoscopic surgery is abnormal. This finding, in combination with hypotension and other signs of poor perfusion, strongly suggests possible internal bleeding requiring urgent provider notification.
• Hypoactive bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery due to anesthesia and reduced gut motility. They are not an immediate sign of a critical complication unless accompanied by abdominal distension or severe pain, they should however be monitored.
• Heart rate 60/min: A heart rate of 60/min is at the lower limit of normal. Although 60/min is still technically within normal range, the trend of decreasing heart rate from baseline 90 beats/min, especially in the setting of hypotension and signs of poor perfusion, is concerning. This decline may indicate worsening hemodynamic status and must be monitored closely for further deterioration..
• Pedal pulse +1 bilateral: Diminished pedal pulses (+1) indicate reduced peripheral circulation. In isolation, it may not be critical, but when combined with hypotension and cool skin, it becomes part of the overall picture suggesting decreased perfusion and should be monitored carefully.

Rationale:

A. Triiodothyronine: Triiodothyronine (T3) measures thyroid function and is not related to anticoagulation therapy. It is important for evaluating thyroid disorders but has no role in monitoring the effects of warfarin.

B. Arterial blood gases: Arterial blood gases (ABGs) assess oxygenation, ventilation, and acid-base balance, not anticoagulation status. ABGs are not used to monitor warfarin therapy.

C. Serum potassium: Serum potassium levels are crucial for cardiac and muscle function but are not affected directly by warfarin use. Potassium monitoring is more critical with diuretics or certain cardiac medications, not anticoagulants like warfarin.

D. Prothrombin time: Prothrombin time (PT) measures how long it takes blood to clot and is directly affected by warfarin therapy. Monitoring PT (and the related INR) ensures that the warfarin dose maintains therapeutic anticoagulation without causing excessive bleeding.