A nurse is planning care for a client who is 6 hours post-operative following an exploratory laparotomy. Which of the following nursing actions are appropriate to reduce the risk of potential complications? (Select all that apply.)
- Auscultate all four quadrants of the abdomen for bowel sounds prior to performing abdominal palpation.Answer
- Instruct the client to use a splint pillow while performing deep breathing and coughing exercises.Answer
- CDelegate the routine assessment of the surgical dressing for drainage to the unlicensed assistive personnel (UAP).
- DPlace a firm pillow directly under the client's knees to minimize tension on the abdominal incision.
- EAnticipate laboratory results indicating respiratory alkalosis if the client develops shallow, restricted breathing.
- Monitor for a narrowing pulse pressure and mild tachycardia as early systemic signs of internal hemorrhage.Answer
Answer
The correct actions include auscultating the abdomen before palpation, instructing the client to use a splint pillow during deep breathing, and monitoring for a narrowing pulse pressure with mild tachycardia.
Appropriate risk reduction strategies for a post-operative abdominal surgery client include assessing the abdomen in the correct sequence (auscultation before palpation) to ensure accurate data, using a splint pillow during respiratory exercises to prevent wound dehiscence and atelectasis, and monitoring for early systemic signs of shock such as a narrowing pulse pressure and mild tachycardia.
Step-by-Step Solution
Key Concept
Post-Operative Risk Reduction and Complication Prevention