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Difficulty: MediumPhysiological Adaptation

An older adult client is 24 hours postoperative following a bowel resection. The practical nurse (PN) is assisting with data collection and bedside care. Which actions indicate that the PN is safely prioritizing the client's physiological adaptation? Select all that apply.

  1. Promptly reporting a heart rate of 112 beats/min and a blood pressure of 98/60 mm Hg to the supervising nurse.Answer
  2. B
    Attributing the client's new-onset confusion and agitation to standard age-related cognitive decline.
  3. C
    Administering a prescribed oral analgesic for incisional pain before assessing a newly developed rapid respiratory rate.
  4. Inspecting the surgical dressing for excessive drainage and monitoring intake and output to assess fluid volume status.Answer
  5. Encouraging the client to perform deep breathing and coughing exercises while splinting the abdominal incision.Answer
  6. F
    Delaying notification of a 20 mL/hour urine output because the client's systolic blood pressure remains greater than 100 mm Hg.

Answer

The correct actions include reporting early signs of hemodynamic instability (tachycardia and borderline hypotension), monitoring fluid status via intake/output and dressing checks, and promoting respiratory adaptation through deep breathing and splinting.
The appropriate actions prioritize the client's physiological adaptation by directly addressing and monitoring postoperative risks. Reporting a heart rate of 112 beats/min and blood pressure of 98/60 mm Hg is crucial because these are early compensatory signs of hypovolemic shock. Inspecting the dressing and monitoring intake/output provides direct data collection regarding fluid balance and bleeding risk. Encouraging deep breathing with splinting prevents atelectasis and pneumonia, which are common respiratory complications following abdominal surgery.

Step-by-Step Solution

1
Evaluate the client's physiological status and risk for postoperative complications.
The client is at risk for hypovolemia, respiratory compromise, and infection.
Bowel resection surgery causes fluid shifts, blood loss, and abdominal pain that restricts deep lung expansion.
2
Identify priority findings that require immediate intervention or escalation.
Tachycardia, borderline hypotension, and low urine output are early signs of shock. New-onset confusion indicates poor perfusion or hypoxia.
Addressing Airway, Breathing, and Circulation (ABC) issues takes precedence over routine pain management.
3
Select the nursing actions that demonstrate safe and appropriate care.
Reporting vital sign changes, monitoring fluid balance, and promoting lung expansion are correct. Dismissing confusion, ignoring low urine output, or prioritizing pain over respiratory distress are incorrect.
Safe PN practice requires recognizing acute deterioration and escalating changes appropriately rather than normalizing them.

Key Concept

Postoperative Physiological Adaptation and Complication Recognition
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Topics

Physiological Adaptation

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