The nurse is caring for a patient who had an ovarian cyst removed under general anesthesia 12 hours ago. Which is the most important goal for this patient?

Question

a. The patient will cough and deep breathe every hour for 48 hours.
b. The patient will have bowel sounds within 24 hours after surgery.
c. The patient will exercise the feet and an-kles 3 times this shift.
d. The patient will ambulate tonight and 3 times tomorrow.

Answer 1

D
The most important goal for this patient is ambulation because it promotes lung expansion, res-toration of peristalsis, peripheral perfusion, venous return, and tissue integrity and thereby de-creases atelectasis and prevents pneumonia, constipation, thromboembolic events, skin break-down, and infection. The patient should not cough and deep breathe every hour. She must be allowed to sleep. Establishing bowel sounds within 24 hours after surgery is an unrealistic goal. If the intestines are emptied before surgery, restoring bowel sounds can take longer than 1 day, and producing a bowel movement often takes 4 to 5 days. Ankle and foot exercises promote perfu-sion and venous return, which help to prevent circulatory problems, but ambulation is best.