The nurse is caring for a client after removal of an ovarian cyst under general anesthesia 12 hours ago. Which is the most important goal for this client?

Question

1. The client will cough and deep breathe every hour for 48 hours.
2. The client will have bowel sounds within 24 hours after surgery.
3. The client will exercise the feet and ankles three times this shift.
4. The client will ambulate three times a day during hospitalization.

Answer 1

4
4. The most important goal for this client is ambulating three times a day and it is the most comprehensive goal because it promotes lung expansion, restoration of peristalsis, peripheral perfusion, venous return, and tissue integrity and thereby decreases atelectasis and prevents pneumonia, constipation, thromboembolic events, skin breakdown, and infection.
1 and 3. The remaining options are less comprehensive in their scope. Coughing and deep breathing help prevent atelectasis, pneumonia, and infection, whereas ankle and foot exercises promote perfusion and venous return.
2. Establishing bowel sounds within 24 hours after surgery is an unrealistic goal. If the intestines are emptied preoperatively, restoring bowel sounds can longer than 1 day and producing a bowel movement often takes 4 to 5 days.