Author Question: A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. ... (Read 109 times)

misspop · **on:** Jun 25, 2018

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?

a. Teach the patient to fully exhale into the incentive spirometer.
b. Administer ordered analgesic medications before these activities.
c. Ask the patient to state two possible complications of immobility.
d. Encourage the patient to state the purpose of splinting the incision.

Question 2

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate?

a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.

Koolkid240 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis.

Answer to Question 2

ANS: C
Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.