A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assess fluid intake every 24 hr.

Ambulate three times a day.

Assist with deep breathing and coughing.

Monitor the incision site for findings of infection.

Answer and Explanation

The Correct Answer is C

- A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.

- B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.

- C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.

- D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.

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Correct Answer is {"dropdown-group-1":"A"}

Explanation

Cardiovascular abnormalities are a significant concern due to electrolyte imbalances caused by recurrent vomiting, which can lead to an irregular heartbeat or even heart failure. Hyponatremia, which is a low sodium level in the blood, is another risk associated with the excessive purging of food and fluids.

A. Instruct a staff member to maintain a log of emergency care provided. B. Apply cervical spine collars to children who have suspected neck trauma. C. Notify guardians of the emergency and injuries to their children. D. Survey the scene for potential hazards to staff and children.

Correct Answer is D

Explanation

A. Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.

B. Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.

C. Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.

D. Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.

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A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

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