During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and feelings of malaise.
The client’s vital signs are an oral temperature of 101.80F (38.8° C), a blood pressure of 100/50 mm Hg, a heart rate of 104 beats/minute, and a respiratory rate of 18 breaths/minute.
What is the appropriate action for the nurse to take?

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated

temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.

Choice B rationale

Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.

Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.

Choice C rationale

Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.

Choice D rationale

Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.