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Day 1 1300: A 45-year-old male client with a history of Crohn’s disease is admitted to the medical surgical unit from the post-anesthesia unit after a small bowel resection two hours prior. Client alert and oriented x4, somnolent. Bilateral breath sounds clear to auscultation; even unlabored, heart sounds S1 and S2, systolic murmur noted, peripheral pulses 3 , capillary refill 2 seconds, skin warm, dry, bowel sounds hypoactive x 4 quadrants, mid-abdominal dressing dry and intact. IV 18g right cephalic vein, site benign, 0.9% normal saline infusing 125 m L/hr. Indwelling urinary catheter draining, 75 mL of amber urine. T 99.0°F (37.2°C), P 88, RR 20, BP 128/76 mmHg, mean arterial pressure 93 mmHg, pulse oximetry on room air 99%, incisional pain 6/10. Client states, “I am so sleepy, and I feel kind of nauseated.” Weight upon admission 67 kg, ht. 5′ 6″ BMI 23.9 1. Which assessment finding requires immediate follow-up ? (Select all that apply. One or more responses may be correct) • Bowel sounds • Incisional Pain • Nausea • Urine output • Heart murmur • Somnolence
SCIENCE
HEALTH SCIENCE
NURSING

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