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Difficulty: HardReduction of Risk Potential

A nurse in the surgical intensive care unit is planning care for a 5454-year-old client who is 44 hours postoperative following an emergency bowel resection and formation of a temporary colostomy due to an intestinal perforation. The client is receiving continuous intravenous (IV) fluids and has an arterial line in place for hemodynamic monitoring. Which nursing actions are essential to reduce the risk of physiological complications? Select all that apply.

  1. Assess the stoma for a dark purple or black appearance and immediately report this finding to the surgeon.Answer
  2. B
    Maintain the client in a strict supine position with the head of the bed flat to maximize central venous return.
  3. C
    Palpate the abdominal surgical area for rigidity and guarding prior to auscultating for the return of bowel sounds.
  4. Monitor the arterial line tracing for a narrowing pulse pressure as an early physiological indicator of hypovolemic shock.Answer
  5. E
    Document an arterial blood gas result of pH=7.49\text{pH} = 7.49 and PaCO2=29 mmHg\text{PaCO}_2 = 29 \text{ mmHg} as a normal, expected postoperative finding.
  6. Verify the chemical compatibility of all prescribed intermittent IV medications with the primary continuous fluid infusion.Answer

Answer

The essential actions to reduce risk potential are assessing the stoma for ischemic changes (dark purple or black appearance), monitoring the arterial line for a narrowing pulse pressure, and verifying intravenous medication compatibility.
Stoma ischemia (indicated by a dark purple or black stoma) is a surgical emergency requiring immediate reporting to preserve tissue viability. Monitoring for a narrowing pulse pressure is a critical assessment skill, as this subtle hemodynamic change often precedes frank hypotension in early hypovolemic or hemorrhagic shock. Finally, verifying intravenous medication compatibility is a fundamental safety measure that prevents drug precipitation and catheter occlusion, directly reducing the risk of intravenous therapy complications.

Step-by-Step Solution

1
Evaluate the client's postoperative physiological risks based on the surgical procedure and present monitoring equipment.
The client is at high risk for bowel ischemia, hypovolemic shock, respiratory complications, and intravenous therapy errors.
Identifying priority physiological risks directs the nurse to focus on assessments that detect life-threatening complications early.
2
Analyze each proposed intervention to determine if it safely mitigates or inadvertently exacerbates the identified physiological risks.
Assessing stoma perfusion, monitoring pulse pressure, and checking IV compatibility are correctly identified as protective interventions. The other actions represent clinical errors in positioning, assessment sequence, and lab interpretation.
Safe nursing practice requires distinguishing between evidence-based risk reduction strategies and unsafe actions that could harm a vulnerable postoperative client.

Key Concept

Postoperative Risk Reduction and Hemodynamic Monitoring
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Topics

Reduction of Risk Potential

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