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Soru

Zorluk: ZorReduction of Risk Potential

A nurse is planning care for a client who is 12 hours post-operative following an exploratory laparotomy and small bowel resection. The client has a nasogastric (NG) tube set to low continuous suction and a surgical drain in place. To reduce the risk of potential complications, which of the following nursing interventions should the nurse include in the plan of care? (Select all that apply.)

  1. Elevate the head of the client's bed to at least 30 degrees.Cevap
  2. B
    Palpate all four abdominal quadrants for rigidity prior to auscultating for bowel sounds.
  3. C
    Document arterial blood gas values of pH 7.28, PaCO2 38 mm Hg, and HCO3 16 mEq/L as an expected outcome of gastric suctioning.
  4. Notify the healthcare provider if the client exhibits a narrowing pulse pressure alongside a steadily increasing heart rate.Cevap
  5. E
    Maintain the client in a flat, supine position with legs fully extended to prevent tension on the abdominal suture line.
  6. Instruct the client to firmly press a pillow against the surgical incision during coughing and deep breathing exercises.Cevap

Cevap

The appropriate interventions to include in the plan of care are elevating the head of the bed, notifying the provider of a narrowing pulse pressure with tachycardia, and instructing the client to splint the incision during breathing exercises.
Appropriate risk reduction for this client involves elevating the head of the bed to prevent aspiration and promote lung expansion, acting on early signs of shock (such as a narrowing pulse pressure and tachycardia), and teaching the client to splint the abdominal incision to prevent dehiscence during coughing.

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1
Analyze the client's clinical context and risk factors.
The client is post-laparotomy with an active NG tube, which introduces risks for respiratory compromise, aspiration, hypovolemia, internal bleeding, and acid-base imbalances.
Identifying potential post-operative complications directs the selection of appropriate, proactive preventive interventions.
2
Evaluate each intervention for physiological safety and alignment with best practice.
Elevating the bed prevents aspiration. Splinting prevents dehiscence while enabling lung expansion. Identifying narrowing pulse pressure detects early shock. The other options present unsafe actions or misinterpretations of critical data.
Nursing actions must directly reduce risk without introducing new complications or missing subtle signs of deterioration.

Anahtar Kavram

Post-operative risk reduction requires the proactive prevention of respiratory complications, adherence to correct physical assessment sequences, and the early identification of physiological deterioration such as hypovolemic shock or acid-base imbalances.
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Reduction of Risk Potential

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