A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assess fluid intake every 24 hr.

Ambulate three times a day.

Assist with deep breathing and coughing.

Monitor the incision site for findings of infection.

Answer and Explanation

The Correct Answer is C

- A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.

- B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.

- C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.

- D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.

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Correct Answer is C

Explanation

A. Constipation is not a common complication of vacuum-assisted birth. It may be related to other factors such as dehydration, opioid use, or decreased mobility.
B. Urinary urgency is not a common complication of vacuum-assisted birth. It may be related to other factors such as bladder trauma, infection, or diuretic use.
C. Cervical laceration is a common complication of vacuum-assisted birth. It occurs when the vacuum cup causes damage to the cervix during delivery. It can lead to bleeding, infection, or cervical incompetence in future pregnancies.
D. Retained placenta is not a common complication of vacuum-assisted birth. It may be related to other factors such as placenta accreta, uterine atony, or manual removal of the placenta.

A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air B. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain E. None F. None

Correct Answer is D

Explanation

The correct answer is D

Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.

Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.

Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.

Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.

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A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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