The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored
The patient's pulse oximetry is 96% on room air. What is the priority action of the nurse?
a.
Administer a dose of the prescribed pain medication.
b.
Administer 2 L of oxygen via nasal cannula.
c.
Obtain an order from the physician for a chest x-ray.
d.
Ensure that the patient is using the spirometer 10 times every hour.
ANS: D
The assessment findings indicate that the patient most likely has atelectasis, so the nurse should ensure that the patient is using the incentive spirometer 10 times every hour to facilitate expansion and reinflation of alveoli. Administering prescribed pain medication is not the priority and may further suppress the patient's respiratory drive. The patient's pulse oximetry is 96% on room air so supplemental oxygen is not needed. A chest x-ray may be ordered if the patient's condition worsens or does not improve with regular spirometer use.
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