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Question

Difficulty: MediumReduction of Risk Potential

A client is recovering on the medical-surgical unit shortly after undergoing an exploratory laparotomy and intestinal resection. To promptly detect and mitigate potential postoperative complications, which interventions should the nurse implement? Select all that apply.

  1. Instruct the client to firmly support the abdominal incision with a pillow when coughing.Answer
  2. B
    Palpate the four abdominal quadrants for distention prior to auscultating for the return of bowel sounds.
  3. Evaluate vital sign trends closely for the presence of a narrowing pulse pressure and mild tachycardia.Answer
  4. D
    Assign the unlicensed assistive personnel to perform the initial assessment of the surgical dressing for active bleeding.
  5. Verify that prescribed intermittent intravenous medications are compatible with the primary continuous fluid infusion.Answer
  6. F
    Position the client flat on their back with the legs fully extended to maintain spinal alignment.

Answer

The appropriate interventions to reduce postoperative risk include instructing the client to splint the incision, evaluating vital signs for early indicators of shock (such as a narrowing pulse pressure and tachycardia), and verifying intravenous medication compatibility prior to administration.
The correct interventions focus on minimizing physiological stress and identifying complications early. Splinting the incision prevents wound dehiscence. Monitoring for a narrowing pulse pressure and tachycardia identifies early hypovolemic shock before severe decompensation occurs. Verifying IV compatibility prevents the dangerous infusion of precipitated medications.

Step-by-Step Solution

1
Analyze the clinical scenario.
The client is in the early postoperative phase after major abdominal surgery.
This specific surgical procedure places the client at high risk for hemorrhage, ileus, wound dehiscence, and respiratory complications.
2
Evaluate each proposed intervention against physiological principles of risk reduction.
Splinting, hemodynamic monitoring, and IV compatibility checks actively reduce physical and pharmacological risks.
These actions directly address vulnerability to wound stress, undiagnosed internal bleeding, and medication administration errors.
3
Identify contraindicated interventions.
Palpating before auscultation, delegating initial wound assessments, and placing the client completely flat are rejected.
These actions violate the standard sequence of abdominal assessment, scope of practice regulations, and proper postoperative biomechanics, thereby increasing client risk.

Key Concept

Postoperative Risk Reduction and Safe Care Environment
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Topics

Reduction of Risk Potential

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