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Difficulty: MediumBasic Care and Comfort

A practical nurse is caring for a client who is on postoperative day 2 following an exploratory laparotomy with a large midline abdominal incision. The client reports moderate incisional pain and nausea. Which basic care and comfort actions should the nurse implement? Select all that apply.

  1. Assist the client to hold a folded blanket or pillow firmly over the incision when coughing.Answer
  2. B
    Position the client flat on their back with legs fully extended to prevent joint contractures.
  3. Elevate the head of the bed to a semi-Fowler's position with the client's knees slightly bent.Answer
  4. D
    Massage the client's calf muscles firmly if they report aching and stiffness in their legs.
  5. Provide frequent oral care, including swabbing the mouth with moistened sponges.Answer
  6. F
    Direct the unlicensed assistive personnel (UAP) to assess the surgical incision for signs of active bleeding.

Answer

The correct actions are assisting the client to splint the incision when coughing, positioning them in a semi-Fowler's position with slightly bent knees, and providing frequent oral care.
Splinting the abdominal incision provides external support and minimizes pain during necessary respiratory exercises like coughing. Assisting the client into a semi-Fowler's position with slightly flexed knees relaxes the abdominal muscles and decreases tension on the surgical wound, effectively minimizing pain. Providing frequent oral care alleviates the physical discomfort associated with nausea and dry mucous membranes.

Step-by-Step Solution

1
Analyze the client's surgical history and current symptoms.
The client had major abdominal surgery (laparotomy) and is currently experiencing incisional pain and nausea.
Identifying the affected body system and specific symptoms guides the selection of appropriate, targeted comfort measures.
2
Evaluate interventions that directly address abdominal incisional pain.
Splinting the incision with a pillow and placing the client in a semi-Fowler's position with flexed knees are safe, effective methods to reduce abdominal muscle tension and pain.
Basic care interventions for abdominal surgery aim to minimize mechanical stress on the healing wound.
3
Determine appropriate comfort measures for nausea.
Frequent oral hygiene safely promotes comfort without risking aspiration or violating dietary restrictions.
Oral care removes unpleasant tastes and moistens mucous membranes, which can ease nausea.
4
Identify unsafe or out-of-scope interventions.
Flat positioning worsens abdominal pain, calf massage creates a high risk for pulmonary embolism, and delegating assessment tasks violates safe assignment guidelines.
Patient safety and adherence to legal scope of practice are paramount when planning care.

Key Concept

Basic comfort measures and safe positioning for clients following abdominal surgery.
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Topics

Basic Care and Comfort

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