A patient who had abdominal surgery is complaining of "gas pains" and has distention of the abdomen and flatus. To promote patient comfort, the nurse should advise:
lying supine with knees flexed.
early ambulation
turning to the left side.
drinking fluids that are very hot.
The Correct Answer is B
A. Lying supine with knees flexed. Lying supine with knees flexed is a common position that can help relieve abdominal discomfort by relaxing the abdominal muscles and allowing gas to pass more easily.
B. Early ambulation: Early ambulation promotes the movement of gas through the intestines, which helps relieve bloating and discomfort. Moving helps stimulate peristalsis and reduces the risk of constipation or gas accumulation postoperatively.
C. Turning to the left side. Although turning to the left side may help with digestion, early ambulation is the most effective intervention for promoting the passage of gas and alleviating abdominal distention and discomfort.
D. Drinking fluids that are very hot: Hot liquids may irritate the stomach and intestines and are not a recommended strategy for relieving gas pain. Cool or room-temperature fluids are typically better tolerated postoperatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.
B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.
C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.
D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.
Correct Answer is C
Explanation
A. IV line patency: IV access is important for fluid and medication administration, but it is not the highest priority immediately postoperatively.
B. Urine output: Monitoring urine output is important for assessing kidney function and fluid balance, but airway management takes precedence.
C. Airway patency: The priority in the immediate postoperative period is maintaining a patent airway, as patients are at risk for respiratory complications such as obstruction, hypoxia, and aspiration due to anesthesia effects.
D. Wound drainage: Assessing wound drainage is necessary to monitor for excessive bleeding or infection, but it is not the top priority compared to airway patency.
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