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Postoperative Phase
Postoperative Phase ( 9 Questions)
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?
Administer oxygen via nasal cannula. This is not the priority action because the patient's oxygen saturation is 92%, which is within the normal range of 90% to 100%. Oxygen therapy may be helpful, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria.
Increase the rate of intravenous fluids. This is not the priority action because the patient may have fluid overload or bleeding as a result of the major abdominal surgery. Increasing the rate of intravenous fluids without knowing the patient's fluid status and blood loss may worsen the patient's condition and lead to complications such as pulmonary edema, heart failure, or hemorrhage.
Notify the physician or surgeon. This is the priority action because the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, and urine output is 20 mL/h. These are signs of hypovolemic shock, which is a life-threatening condition that occurs when there is inadequate blood volume to maintain tissue perfusion. Hypovolemic shock can be caused by hemorrhage, dehydration, burns, or severe vomiting and diarrhea. The patient needs immediate medical attention and interventions such as blood transfusion, fluid resuscitation, vasopressors, and surgery to stop the bleeding source.
Administer pain medication. This is not the priority action because the patient's pain level is not mentioned in the question. Pain medication may be indicated for postoperative pain management, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria. Pain medication may also lower the blood pressure further and mask the signs of shock.
Choice A reason:
Administer oxygen via nasal cannula. This is not the priority action because the patient's oxygen saturation is 92%, which is within the normal range of 90% to 100%. Oxygen therapy may be helpful, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria.
Choice B reason:
Increase the rate of intravenous fluids. This is not the priority action because the patient may have fluid overload or bleeding as a result of the major abdominal surgery. Increasing the rate of intravenous fluids without knowing the patient's fluid status and blood loss may worsen the patient's condition and lead to complications such as pulmonary edema, heart failure, or hemorrhage.
Choice C reason:
Notify the physician or surgeon. This is the priority action because the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, and urine output is 20 mL/h. These are signs of hypovolemic shock, which is a life-threatening condition that occurs when there is inadequate blood volume to maintain tissue perfusion. Hypovolemic shock can be caused by hemorrhage, dehydration, burns, or severe vomiting and diarrhea. The patient needs immediate medical attention and interventions such as blood transfusion, fluid resuscitation, vasopressors, and surgery to stop the bleeding source.
Choice D reason:
Administer pain medication. This is not the priority action because the patient's pain level is not mentioned in the question. Pain medication may be indicated for postoperative pain management, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria. Pain medication may also lower the blood pressure further and mask the signs of shock.