Case Study: The nurse is caring for a 66-year-old client who…
Case Study: The nurse is caring for a 66-year-old client who has a history of chronic obstructive pulmonary disease (COPD) and is recovering from an explorative laparotomy 5 days ago. 1105: Client is alert, oriented × 4, and follows all commands. Chest expansion equal with an anteroposterior ratio of 1:1. Respirations unlabored with diminished breath sounds auscultated in bilateral bases. Heart tones regular. Skin warm and dry with dependent nonpitting lower extremity edema, capillary refill >3 seconds, and pulses palpable throughout. Abdominal dressing intact. Surgical incision below dressing is red and edematous with a pungent odor. Abdomen large, round, soft, and tender to light palpation. Bowel sounds present in all quadrants. Client ambulates with assistance for toileting and in the hallway. VS: T 100.6°F (38.1°C); HR 77 beats/min; RR 15 breaths/min; BP 138/53 mm Hg; SpO2 95% on oxygen at 4 L/min via NC. Reports pain at incision site. Complete the following sentence by selecting from the list of word choices below.The client findings that require immediate follow-up are [wordchoicea] and [wordchoiceb]
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