The nurse is caring for a client who has a core temperature of 97°F (36.1°C) post-op in the post-anesthesia care unit. What action(s) will the nurse take in light of this finding? (Select all that apply)

Notify the surgeon of the blood pressure: While notifying the surgeon of the elevated blood pressure is important, it is not the immediate first action. The nurse should first address the elevated blood pressure by administering the prescribed antihypertensive medication. Once the medication is given, the nurse can then notify the surgeon if the blood pressure remains elevated or if there are any other concerns.

Choice B reason:

Document the blood pressure on the pre-op checklist: Documentation is crucial for maintaining accurate medical records, but it is not the first action in this scenario. The nurse should prioritize administering the antihypertensive medication to manage the client’s elevated blood pressure. After addressing the immediate concern, the nurse can document the blood pressure and any interventions taken.

Choice C reason:

Have the client relax and take deep breaths: Encouraging the client to relax and take deep breaths can help lower blood pressure temporarily, but it is not a substitute for administering the prescribed antihypertensive medication. This action can be taken in conjunction with medication administration but should not be the first or only action.

Choice D reason:

Administer the antihypertensive medication: Administering the antihypertensive medication is the correct first action. The client’s blood pressure is significantly elevated at 174/88, and the medication is necessary to manage this condition. According to perioperative guidelines, most antihypertensive medications should be continued until surgery to prevent complications such as hypertensive crises. Administering the medication will help stabilize the client’s blood pressure and reduce the risk of perioperative complications.

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.