. The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?
Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy.
Provide the patient with a heating pad alternated with a cold pack for incisional pain.
Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.
Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.
The Correct Answer is C
A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.
B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.
C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.
D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.
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Correct Answer is B
Explanation
A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.
Correct Answer is D
Explanation
A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.
B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.
C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.
D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.