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Difficulty: HardReduction of Risk Potential

A clinical nurse evaluates a client who is 88 hours post-operative following a laparoscopic Roux-en-Y gastric bypass. Which of the following nursing actions or clinical judgments are appropriate to reduce the risk of physiological decompensation? (Select all that apply.)

  1. Administering a prescribed intravenous analgesic 3030 minutes before assisting the client with incentive spirometry.Answer
  2. B
    Maintaining the client in a completely supine position to facilitate uninterrupted sleep and reduce incisional tension.
  3. Notifying the rapid response team if the client develops sudden restlessness, mild tachycardia, and a narrowing pulse pressure.Answer
  4. D
    Documenting an arterial blood gas result of pH 7.287.28, PaCO2\text{PaCO}_2 5858 mm Hg, and HCO3−\text{HCO}_3^- 2424 mEq/L as an expected residual effect of anesthesia.
  5. E
    Delaying the report of sudden, severe left shoulder pain until after observing the client's response to the next scheduled analgesic.
  6. Assisting the client with early ambulation in the unit hallway to promote pulmonary expansion and venous return.Answer

Answer

The appropriate actions are administering analgesics before spirometry, notifying the rapid response team for early signs of shock, and assisting with early ambulation.
Clients recovering from major bariatric surgery are at elevated risk for cardiopulmonary complications and anastomotic leaks. Providing intravenous analgesia before pulmonary hygiene (incentive spirometry) ensures the client can tolerate deep diaphragmatic breathing. Early ambulation is a core standard of care to prevent deep vein thrombosis and promote gastrointestinal motility. Furthermore, acute restlessness paired with a narrowing pulse pressure and mild tachycardia are classic early, subtle indicators of compensatory shock (often due to hemorrhage or sepsis from an internal leak), which necessitates immediate escalation to a rapid response team.

Step-by-Step Solution

1
Evaluate post-operative respiratory care principles for bariatric clients.
Pain control prior to incentive spirometry is essential to allow deep diaphragmatic excursion. Early ambulation is also critical to prevent atelectasis and venous stasis.
Bariatric clients are at extremely high risk for pulmonary complications due to restricted chest wall expansion and abdominal pain.
2
Analyze the significance of the presented arterial blood gas (ABG) values.
A pH of 7.287.28 combined with a PaCO2\text{PaCO}_2 of 5858 mm Hg indicates acute, uncompensated respiratory acidosis.
This is a pathological state of hypoventilation that signals impending respiratory failure, not a benign residual effect of anesthesia.
3
Identify clinical signs of severe postoperative complications such as anastomotic leak or hemorrhage.
Restlessness, tachycardia, and a narrowing pulse pressure are early compensatory mechanisms for shock. Unrelieved left shoulder pain (Kehr's sign) indicates phrenic nerve irritation from peritonitis or intra-abdominal bleeding.
Recognizing early physiological deterioration prevents progression to irreversible shock or systemic sepsis.
4
Determine the correct client positioning requirements.
The client must be placed in a semi-Fowler's position, not completely supine.
Semi-Fowler's position utilizes gravity to pull abdominal adipose tissue away from the diaphragm, improving lung expansion and reducing tension on the gastrointestinal anastomosis.

Key Concept

Early recognition of subtle physiological deterioration and application of appropriate post-operative pulmonary/hemodynamic interventions reduces risk potential.
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Reduction of Risk Potential

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