A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

Choice A rationale:

Awaiting biopsy results can certainly cause anxiety and stress, but it doesn't directly impact the physiological mechanisms that modulate pain perception.

While a patient awaiting biopsy results may be more attentive to their bodily sensations, including pain, the anxiety itself is not the primary driver of a lowered pain threshold.

It's important to address the patient's concerns and provide emotional support, but this alone may not be sufficient to manage pain effectively if anxiety is not the primary factor.

Choice B rationale:

Anxiety activates the sympathetic nervous system, which triggers the "fight-or-flight" response. This cascade of physiological changes includes:

Increased heart rate and blood pressure Muscle tension

Dilated pupils

Heightened awareness of bodily sensations

These physiological changes can amplify pain signals and lower the pain threshold, meaning that a person who is anxious may perceive pain more intensely than someone who is calm and relaxed.

This is because anxiety can reduce the effectiveness of the body's natural pain-inhibiting mechanisms, such as the release of endorphins and serotonin.

Choice C rationale:

Difficulty sleeping can also contribute to pain, but its effect on pain threshold is less direct than that of anxiety. Sleep deprivation can lead to:

Increased irritability Decreased pain tolerance Impaired cognitive function

These factors can make it more difficult to cope with pain, but they don't directly lower the threshold at which pain signals are perceived.

Choice D rationale:

Pain threshold varies among individuals due to a variety of factors, including: Genetics

Past experiences with pain Psychological factors Cultural beliefs

Coping mechanisms

It is incorrect to assume that all patients who have had surgery will have the same pain threshold.