The nurse is caring for a client who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the client? (Select all that apply.)
a. Monitor and record accurate intake and output (I&O).
b. Remind the client to use the incentive spirometer twice daily.
c. Change abdominal dressings daily using medical asepsis.
d. Remind the client daily to use patient-controlled analgesia (PCA) before pain becomes severe.
e. Keep the head of the client's bed elevated whenever possible.
f. Irrigate the nasogastric tube with normal saline every 8 hours PRN.
A, D, E
I&O should be recorded to monitor for fluid overload or deficit. Pain medication is most effective when taken before pain becomes severe. Keep the client's head of the bed elevated to prevent reflux. The spirometer should be used at least every hour to prevent atelectasis and pneumonia. Surgical asepsis (sterile technique) must be used for dressing changes and the site must be assessed each shift, necessitating a dressing change each shift.
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