A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Choice A reason:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B reason:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C reason:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D reason:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

Choice A reason:

Keeping the dressing clean and dry prevents contamination and infection of the wound. It also helps the wound heal faster by protecting it from further injury. This is a standard instruction for wound care after a minor surgical procedure.

Choice B reason:

Changing the dressing every day or as needed helps keep the wound clean and allows the doctor or nurse to monitor the healing process. It also prevents the dressing from sticking to the wound or becoming too wet or soiled. This is another common instruction for wound care after a minor surgical procedure.

Choice C reason:

Washing the wound with soap and water is not recommended for wound care after a minor surgical procedure. Soap can irritate the wound and delay healing. Water can wash away the protective scab and cause bleeding. The wound should be rinsed with sterile water or saline solution instead.

Choice D reason:

Applying antibiotic ointment to the wound is not advised for wound care after a minor surgical procedure unless prescribed by the doctor or surgeon. Antibiotic ointment can cause allergic reactions, increase resistance to bacteria, or interfere with the healing process. The wound should be covered with a sterile dressing and left alone.

Choice E reason:

Reporting any signs of infection to the physician or surgeon is an important instruction for wound care after a minor surgical procedure. Signs of infection include redness, swelling, warmth, pain, pus, fever, or foul odor. Infection can delay healing, cause complications, or spread to other parts of the body.