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Day 2 1300: The client appears restless with periods of confusion, skin cool, moist, peripheral pulses 1+ weak, thready. Dressing removed, mid abdominal incision 17.2 cm, approximated, serosanguinous drainage noted, intact, tender to touch, erythematous—incisional pain 4/10. T 101.0°F (38.3°C), pulse 110, respirations 24, blood pressure 100/56 mmHg, mean arterial pressure 71, pulse oximetry on room air 92 6 %. Health care provider notified. Based on the assessment findings, which immediate clinical action is indicated? Indicated Not Indicated Thermal blanket Apply Oxygen IV fluid challenge Morphine bolus Blood Transfusion 45 degree recumbent position
SCIENCE
HEALTH SCIENCE
NURSING

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