18. A nurse is reviewing the plan of care for a client who is postoperative total
abdominal hysterectomy. Postoperatively, the RN documented vital signs as:
temperature 101.4 F, heart rate 88/min., respiratory rate 18/min., and blood
pressure 124/82 mm Hg. Breath sounds are clear bilaterally. Bowel sounds are
absent. An indwelling urinary catheter is patent and urinary output is 30 ml/hr.
Four hours after surgery, the nurse's data now reveals vital signs 102/68 mm Hg,
and urinary output 20 ml/hr. Which of the following are appropriate actions at this
time? Select all that apply.
a. Change the dressing.
b. Call for assistance.
c. Calculate urine output.
d. Check for vaginal bleeding.
e. Continue IV fluid and electrolyte replacement.
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