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.)

Choice A rationale:

STAT orders are urgent and require immediate action. They are typically used for life-threatening situations or when a rapid response is needed to prevent serious harm. In this case, an EKG is important for patients admitted to the cardiac unit, but it is not necessarily an urgent procedure that requires immediate action in all cases.

STAT orders are often given verbally or over the phone, and they are typically written in all capital letters with the word "STAT" prominently displayed.

Examples of STAT orders include medications for cardiac arrest, intubation for respiratory distress, or emergency surgery for a ruptured appendix.

Choice B rationale:

PRN orders are "as needed" orders, meaning they are only carried out when a specific condition or symptom arises. They are not routinely implemented for all patients in a particular unit or setting.

PRN orders allow for flexibility in treatment plans and can help to manage pain, nausea, anxiety, or other symptoms that may fluctuate over time.

Examples of PRN orders include pain medication, anti-nausea medication, or sedatives.

Choice C rationale:

One-time orders are administered only once and are not repeated. They are often used for procedures, diagnostic tests, or medications that are not required on an ongoing basis.

In this case, an EKG is typically a one-time order for patients outside of the cardiac unit, but it becomes a standing order for patients admitted to the cardiac unit due to the increased importance of cardiac monitoring in this setting.

Examples of one-time orders include a chest X-ray, a blood draw, or a dose of antibiotics.

Choice D rationale:

Standing orders are routine orders that are implemented for all patients in a particular unit or setting, unless otherwise specified. They are designed to provide consistent and standardized care, and they often reflect best practices or guidelines for a specific patient population.

Standing orders can help to streamline care processes, reduce the need for individual orders, and ensure that patients receive necessary treatments or interventions without delay.

In this case, the standing order for an EKG upon admission to the cardiac unit ensures that all patients receive this important cardiac assessment, even if the ordering provider does not specifically write an order for it.

Other examples of standing orders in a cardiac unit might include daily weights, regular vital sign checks, or administration of cardiac medications.

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.