The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)

Teach the patient to splint the incision when coughing to minimize pain.

Assist the patient to sit up in the chair and ambulate in the hallway.

Watch the patient use the incentive spirometer and ensure hourly usage.

Dim the lights, provide warm blankets, and maintain a quiet environment.

Maintain patient privacy and use therapeutic touch as desired by the patient.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue).

Steps for splinting the incision:

Place a pillow or folded towel over the incision site.

Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B rationale:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up.

Additional benefits of sitting up and ambulating: Improved circulation

Decreased risk of pneumonia Enhanced recovery from surgery Choice C rationale:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs.

Instructions for using an incentive spirometer:

Sit upright in a chair or bed.

Place the mouthpiece of the spirometer in your mouth and seal your lips around it.

Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds.

Exhale slowly and completely through the mouthpiece.

Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

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Correct Answer is C

Explanation

Choice A rationale:

Incorrect. Patients who develop tolerance to a medication do not typically maintain a stable dose over time. Instead, they often require increasing doses to achieve the same effect.

Physiological adaptation: The body adapts to the presence of the medication, leading to a decreased response over time. This adaptation can occur at various levels, including receptor downregulation, changes in enzyme activity, or alterations in neurotransmitter release.

Individual variability: The rate and extent of tolerance development vary significantly among individuals, influenced by factors such as genetics, age, overall health, and medication type.

Choice B rationale:

Incorrect. Impaired liver or kidney function can affect drug metabolism and elimination, but this is not the primary mechanism of tolerance.

Metabolic impairment: Liver or kidney dysfunction can lead to drug accumulation in the body, potentially increasing the risk of side effects or toxicity. However, this does not necessarily cause tolerance, which is a specific phenomenon of decreased responsiveness to the medication's effects.

Choice C rationale:

Correct. This statement accurately describes the hallmark characteristic of tolerance.

Dose escalation: As tolerance develops, patients often require higher doses of the medication to achieve the same therapeutic effect. This can lead to a cycle of increasing doses and potential risks of adverse effects.

Clinical implications: Tolerance is a significant consideration in medication management, as it can affect treatment efficacy, adherence, and the risk of side effects.

Choice D rationale:

Incorrect. Tolerance can develop even when patients adhere strictly to their prescribed medication regimen. It is a physiological phenomenon that is not solely dependent on patient behavior.

Adherence vs. tolerance: While non-adherence can contribute to treatment failure, it is not the underlying cause of tolerance.

A. Provide meticulous oral care and allow the patient to have ice chips for dry mouth. B. Notify the surgeon immediately and prepare the patient for emergency surgery. C. Keep the patient NPO and document the finding in the patient’s medical record. D. Allow the patient to have clear liquids as tolerated to help bowel function return.

Correct Answer is C

Explanation

Choice A rationale:

While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds.

Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period.

It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.

Choice B rationale:

Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation.

Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis.

These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability.

Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.

Choice D rationale:

Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration.

It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.

Choice C rationale:

Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery.

This allows the bowel to rest and recover from the surgical manipulation.

It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake.

Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress.

This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.

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The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement accurately describes patient tolerance to medications?

Correct Answer is C

Explanation

Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

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The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)