The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.

Choice A reason: Wrapping the feet with warmed blankets may provide comfort and warmth, but it does not address the immediate concern of assessing the circulation status in the lower extremities. It is not the first action to take in this situation.

Choice B reason: Elevating the extremities on pillows can help reduce edema and improve circulation, but it should not be the first action taken. Assessing the pulses is crucial to determine the severity of the circulation issue and guide further interventions.

Choice C reason: Assessing pulses with a vascular doppler is the correct first action. Since the pedal pulses are not palpable, using a vascular doppler can help determine if there is any blood flow in the lower extremities. This assessment is essential to identify potential complications such as arterial occlusion or compromised circulation, which require immediate intervention.

Choice D reason: Evaluating edema for pitting can provide information about the extent of the swelling, but it does not address the immediate concern of assessing blood flow. Assessing pulses with a vascular doppler is a more critical first step to ensure the client's circulation status is evaluated accurately.