A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

A. The client is tolerating clear liquids: Following gastric banding surgery, clients typically begin with clear liquids and gradually progress to more solid foods. Tolerating clear liquids 36 hours post-op is expected and indicates appropriate recovery.
B. The client is voiding at least 250 mL/hr: A urine output of 250 mL/hr is abnormally high and could suggest overhydration or other issues. Normal expected output is around 30–50 mL/hr postoperatively.
C. The client is maintaining bed rest: Prolonged bed rest increases the risk of complications like deep vein thrombosis. Clients are generally encouraged to ambulate early unless contraindicated.
D. The client is consuming 1000 calories daily: At 36 hours post-op, the client is not expected to consume high-calorie meals. Intake is usually limited to small amounts of clear liquids to prevent nausea and stress on the surgical site.

Rationale for Correct Choices:

• Antibiotic prescription: The client presents with signs of a postoperative wound infection: fever (38.8°C), increased WBC count (14,800/mm³), purulent drainage, and incisional swelling. These findings warrant prompt antibiotic therapy to prevent further complications.
• WBC count: The rise in WBC count from 8,000 to 14,800/mm³ over three days is a key indicator of an infectious process, particularly concerning postoperatively. It supports the need for antibiotics.
• Temperature: The client’s fever (38.8°C/101.8°F) is consistent with a systemic response to infection. In combination with the elevated WBC and wound findings, it confirms the need for antimicrobial treatment.

Rationale for Incorrect Choices:

• IV fluids: While fluids are essential postoperatively, the client shows no signs of hypovolemia or dehydration—mucous membranes are moist and blood pressure is stable. Fluids are not the priority.
• Laxative: Although the client hasn’t had a bowel movement, they are passing flatus and show some motility. The acute concern is infection, not constipation, making laxatives inappropriate as the primary intervention.
• Prescription for IV iron: The client has stable but low hemoglobin levels (around 10.3 g/dL), likely due to surgery. However, there’s no acute drop or symptomatic anemia requiring immediate IV iron over addressing infection.
• Hemoglobin: Although low, the hemoglobin level is stable and does not indicate an acute issue. It does not justify antibiotic use or serve as the primary clinical concern at this time.
• Bowel sounds: Hypoactive bowel sounds are common postoperatively and are not indicative of infection alone. They do not support the use of antibiotics directly.
• Blood pressure: The client’s blood pressure remains within normal limits postoperatively and does not show signs of septic or hypovolemic shock. It’s not relevant to initiating antibiotics.
• Transferrin level: Transferrin reflects protein status and iron transport; although low, it doesn’t indicate acute infection. It is unrelated to the decision to initiate antibiotics.
• Skin turgor: Normal skin turgor suggests adequate hydration. There’s no indication of dehydration or fluid imbalance requiring action.
• Bowel movements: Absence of bowel movement is common postoperatively and expected after colon surgery. While important to monitor for ileus, these are not the primary indicators for an antibiotic prescription.