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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.
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The nurse is caring for a patient and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
- A. Have the patient use the incentive spirometer.
- B. Assess the surgical incision for redness and swelling.
- C. Administer the ordered PRN acetaminophen.
- D. Notify the patient's health care provider about the fever.
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
The nurse is caring for a patient who is being transferred from the postanesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?
- A. Assess the patient's pain.
- B. Take the patient's vital signs.
- C. Read the postoperative orders.
- D. Check the rate of the IV infusion.
Correct Answer: B
Rationale: Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.
The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, 'I do not know if I can take care of myself with this patch over my eye.' Which of the following actions is the most appropriate for the nurse to implement?
- A. Refer the patient for home health care services.
- B. Discuss the specific concerns regarding self-care.
- C. Give the patient written instructions regarding care.
- D. Assess the patient's support system for care at home.
Correct Answer: B
Rationale: The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.
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.
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.