A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Measure the client's abdominal girth.

Monitor the client's recent hemoglobin levels.

Prepare for nasogastric tube (NGT) insertion.

Notify the healthcare provider (HCP) of the client's status.

Answer and Explanation

The Correct Answer is D

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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Correct Answer is C

Explanation

A. Determine patellar tendon reflex response. The patellar reflex (knee jerk) assesses function of the L2-L4 spinal nerves, which are below the level of injury (C8-T1) and do not provide information about upper extremity function. While deep tendon reflexes are important, they do not help assess function at the suspected injury level.
B. Check the urinary bladder for distention. Bladder function is controlled by the sacral spinal nerves (S2-S4), which are much lower than the injury level. While bladder dysfunction is common in spinal cord injuries, it does not assess C8-T1 nerve function specifically.
C. Ask the client to grasp an object or form a fist. The C8 and T1 spinal nerves control hand and finger movements, including grip strength. Testing the client’s ability to grasp an object or form a fist helps assess fine motor function and nerve integrity at the injury level. This is the most appropriate way to determine function in the lower cervical and upper thoracic spinal nerves.
D. Apply resistance while the client lifts the legs. Leg movement is controlled by the lumbar and sacral spinal nerves (L2-S2), which are below the injury level. Assessing leg strength does not provide relevant information about C8-T1 function.

A. Respirations are shallow, labored, and 14 breaths/minute. B. Has flaccid upper and lower extremities. C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. D. Is unable to feel sensation in the arms and hands.

Correct Answer is A

Explanation

A. Respirations are shallow, labored, and 14 breaths/minute. A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
B. Has flaccid upper and lower extremities. Flaccid paralysis is an expected finding immediately after a high spinal cord injury due to spinal shock. While this condition requires ongoing monitoring, it is not an immediate life-threatening emergency like respiratory distress.
C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. These vital signs are within normal limits and do not indicate hemodynamic instability. Neurogenic shock, which can occur with high spinal injuries, typically presents with hypotension and bradycardia, but this client’s current BP and HR are stable.
D. Is unable to feel sensation in the arms and hands. Loss of sensation is expected with a cervical spinal cord injury due to nerve pathway disruption. While this finding is significant, it does not require immediate intervention compared to respiratory distress, which is the most urgent priority.

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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