A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Choice A reason:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B reason:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C reason:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D reason:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

Choice A reason:

This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.

Choice B reason:

This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.

Choice C reason:

This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.

Choice D reason:

This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.