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After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which of the following actions should the nurse take?
- A. Reinsert the NG tube.
- B. Give the PRN IV opioid.
- C. Assist the patient to ambulate.
- D. Place the patient on NPO status.
Correct Answer: C
Rationale: Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distension persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.
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The nurse is caring for an older-adult patient who had a surgical repair of a hip fracture 2 days previously and has restrictions on ambulation. Based on this information, which of the following collaborative problems is priority for the patient?
- A. Potential complication: hypovolemic shock
- B. Potential complication: venous thromboembolism
- C. Potential complication: fluid and electrolyte imbalance
- D. Potential complication: impaired surgical wound healing
Correct Answer: B
Rationale: The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.
In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which of the following actions by the nurse is most helpful?
- A. Discuss the complications of immobility and poor cough effort.
- B. Teach the patient the purpose of respiratory care and ambulation.
- C. Administer ordered analgesic medications before these activities.
- D. Give the patient positive reinforcement for accomplishing these activities.
Correct Answer: C
Rationale: The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.
The nurse is caring for a postoperative patient who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?
- A. Notify the surgeon.
- B. Assess for bladder distension.
- C. Assist the patient to ambulate to the bathroom.
- D. Insert a straight catheter as indicated on the PRN order.
Correct Answer: B
Rationale: The initial action should be to assess the bladder for distension. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
- A. Reinforce the dressing.
- B. Take the patient's vital signs.
- C. Recheck the dressing in 1 hour for increased drainage.
- D. Notify the patient's surgeon of a potential hemorrhage.
Correct Answer: B
Rationale: New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
The nurse is caring for a patient who had abdominal surgery two days previously. Which of the following information about the patient is most important to communicate to the health care provider?
- A. The right calf is swollen, warm, and painful.
- B. The patient's temperature is 37.9°C (100.2°F).
- C. The 24-hour oral intake is 600 mL greater than the total output.
- D. The patient complains of abdominal pain at level 6 (0-10 scale).
Correct Answer: A
Rationale: The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2-5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 37.9°C (100.2°F) on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.