A nurse is evaluating the discharge instructions for a client who had a mastectomy with lymph node dissection. The nurse instructs the client to avoid:

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:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped”. or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B reason:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C reason:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D reason:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.