The following 4 questions pertain to this case study:

Exhibits

Indicate which nursing interventions the post-surgical unit nurse should complete. (Select all that apply)

Choice A reason:

Assessing the surgical dressing is crucial to monitor for signs of bleeding, infection, or other complications at the surgical site. The nurse should check the dressing for any excessive drainage, unusual color, or odor, which could indicate an infection or other issues. Ensuring the dressing is intact and clean helps in preventing wound contamination and promotes healing. This assessment is vital in the immediate postoperative period to detect any early signs of complications that may require prompt intervention.

Choice B reason:

Obtaining the vital signs is a fundamental assessment that provides critical information about the patient’s overall physiological status. Vital signs include blood pressure, heart rate, respiratory rate, and temperature. These measurements help in identifying any deviations from the normal ranges that could indicate complications such as hypovolemia, infection, or respiratory distress. Regular monitoring of vital signs allows the nurse to detect and respond to any changes in the patient’s condition promptly. Normal ranges for adults are typically: blood pressure 120/80 mmHg, heart rate 60-100 beats per minute, respiratory rate 12-20 breaths per minute, and temperature around 98.6°F (37°C).

Choice C reason:

Assessing the pain level is essential for effective pain management and patient comfort. Postoperative pain can significantly impact a patient’s recovery and ability to participate in necessary activities such as deep breathing and ambulation. The nurse should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to evaluate the patient’s pain intensity and quality. Effective pain management involves administering prescribed analgesics and evaluating their effectiveness, as well as implementing non-pharmacological interventions as needed. Proper pain control helps in reducing stress, promoting healing, and improving the overall recovery experience.

Choice D reason:

Assessing the respiratory rate and effort is critical to ensure that the patient is breathing adequately and not experiencing respiratory distress. Anesthesia and surgery can affect respiratory function, making it essential to monitor for signs of hypoxia, such as increased respiratory rate, use of accessory muscles, or cyanosis. The nurse should observe the patient’s breathing pattern, listen to breath sounds, and measure oxygen saturation levels using a pulse oximeter. Normal oxygen saturation levels are typically between 95-100%. Prompt identification and management of respiratory issues are crucial to prevent complications such as atelectasis and pneumonia.

Choice E reason:

Asking the patient if they have a ride home is not a priority assessment in the immediate postoperative period. While discharge planning is important, the primary focus should be on stabilizing the patient’s physiological status and addressing any immediate postoperative needs. Ensuring the patient has a ride home can be addressed later in the recovery process, once the patient is stable and ready for discharge. The initial assessments should prioritize monitoring for complications and ensuring the patient’s safety and comfort.

Choice A: Infuse the KCl at a maximum rate of 10 mEq/hr

This is the correct answer. The recommended infusion rate for potassium chloride is generally not to exceed 10 mEq per hour to avoid complications such as hyperkalemia and cardiac arrhythmias. This rate ensures that the potassium is administered safely and effectively, allowing for proper monitoring and adjustment if necessary.

Choice B: Discontinue cardiac monitoring during the infusion

This choice is incorrect. Cardiac monitoring is essential during the infusion of potassium chloride, especially in patients with severe hypokalemia, due to the risk of arrhythmias and other cardiac complications. Continuous monitoring allows for the early detection of any adverse effects and timely intervention.

Choice C: Administer the KCl as a rapid IV bolus

Administering potassium chloride as a rapid IV bolus is dangerous and contraindicated. Rapid infusion can lead to severe hyperkalemia, which can cause fatal cardiac arrhythmias. Potassium chloride should always be administered slowly and diluted in an appropriate volume of fluid.

Choice D: Refuse to give the KCl through a peripheral venous line

While central lines are preferred for higher concentrations of potassium chloride due to the risk of irritation and phlebitis, peripheral lines can be used for lower concentrations and slower infusion rates. Refusing to administer potassium chloride through a peripheral line is not necessary if the infusion is properly managed and monitored.