The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:
no bowel sounds noted during the assessment.
an SPO2 which registers 90% while the client is asleep.
increasing abdominal distention.
a small amount of green-tinged fluid from the nasogastric tube.
The Correct Answer is C
A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.
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Correct Answer is C
Explanation
A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.
Correct Answer is C
Explanation
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.