hard · NCLEX-RN safety
A nurse is monitoring an 82-year-old client who is receiving negative-pressure wound therapy (NPWT) for an open abdominal wound following a hemicolectomy. The client has a history of atrial fibrillation and is currently taking warfarin 5 mg daily, with a therapeutic INR of 2.4. Which of the following clinical findings require immediate emergency intervention by the nurse? Select all that apply.
- Presence of pale pink, serosanguineous fluid coating the tubing and 30 mL in the canister over 12 hours.
- The client reports a sudden onset of severe, throbbing pain at the wound site, and the heart rate rises from 76/min to 118/min.
- Sudden accumulation of 150 mL of bright red, warm fluid in the canister over a 15-minute interval.
- An INR of 2.4 documented on the morning laboratory report.
- A 'Canister Full' alarm sounding with 300 mL of dark, thick yellow-green fluid in the canister.
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