A nurse is caring for a client who has an open abdominal wound and a negative-pressure wound therapy (NPWT) device. Which of the following actions should the nurse take?

Rationale for Correct Choices

• Nasogastric tube: The client is experiencing nausea, vomiting, abdominal distension, firm abdomen, hypoactive/absent bowel sounds, and has not passed flatus since surgery, indicating possible postoperative ileus or gastric distension. Inserting a nasogastric tube can help decompress the stomach, relieve nausea, and prevent further complications such as aspiration.
• Opioid analgesic: The client reports increased incisional pain (5/10) and discomfort associated with abdominal distension. Administering an opioid analgesic as prescribed helps manage pain, allowing for comfort, mobility, and participation in postoperative care.

Rationale for Incorrect Choices

• Chest tube: Chest tubes are used to drain air, blood, or fluid from the pleural space and are not indicated for abdominal distension or postoperative ileus. Additionally, the clients lung sounds are normal with adequate saturation on supplementary oxygen.
• Urinary catheter: The client’s urinary output is adequate (480 mL in 8 hr),averaging 60 mL/hr so a urinary catheter is not necessary at this time and does not address abdominal distension or nausea.
• Antibiotics: There is no evidence of infection at this time. Prophylactic or therapeutic antibiotics are not indicated solely for postoperative pain or nausea without signs of infection.
• Antihypertensive: The client’s blood pressure (104/68 mm Hg) is slightly lower than earlier but does not warrant antihypertensive therapy. Administering such medication could worsen hypotension and perfusion.

Rationale

A. Lethargy: Lethargy is more commonly associated with hypercalcemia, which depresses the central nervous system. In hypocalcemia, neuromuscular excitability is increased, so clients are more likely to experience irritability or paresthesia rather than lethargy.

B. Constipation: Constipation is a manifestation of hypercalcemia due to decreased smooth muscle contractility. Hypocalcemia typically increases neuromuscular excitability and does not generally cause constipation.

C. Positive Chvostek's sign: A positive Chvostek's sign indicates facial muscle twitching in response to tapping over the facial nerve and is a hallmark sign of hypocalcemia. It reflects increased neuromuscular excitability due to low calcium levels and is commonly used in assessment.

D. Muscle flaccidity: Muscle flaccidity occurs with hypercalcemia or decreased neuromuscular activity. In hypocalcemia, muscles are more likely to exhibit tetany, spasms, or cramping due to heightened excitability, rather than flaccidity.