The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client’s vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.
The data that warrant immediate intervention in this scenario are:
1
The data that warrant immediate intervention in this scenario are:
1. The client is alert to name but is unable to tell the nurse the location.
This is a sign of confusion or disorientation, which can indicate a neurological issue such as a brain injury or postoperative complication. It is important to assess the client’s neurological status further and inform the medical team for prompt evaluation and intervention.
2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
This represents a significant imbalance between fluid output and intake. It is important to assess the client’s hydration status, monitor their vital signs, and contact the medical team to address the fluid imbalance promptly. It may indicate issues such as excessive urine output, increased bleeding, or fluid loss.
3. The client’s vital signs are T 97.6ºF, P 88, R 20, and BP 130/80.
These vital signs are within normal range and do not warrant immediate intervention. However, it is important to continue monitoring the vital signs to detect any changes that may occur over time.
4. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Dark-red drainage from the surgical site can indicate bleeding, especially if it is a significant amount. This warrants immediate intervention to assess the extent of bleeding, control it, and prevent further complications. Inform the medical team immediately for evaluation and intervention.
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