The nurse assesses the patient on the first postoperative day after major abdominal surgery. Which is the most important patient outcome that requires follow-up interventions by the nurse?
a. The pain level is 2 on a scale of 0 to 10 after an analgesic.
b. The patient is voiding an average of 45 mL/hr.
c. Bowel sounds are inaudible in all qua-drants.
d. The patient performs breathing exercises every 6 to 8 hours.
D
Increasing the frequency of breathing exercises is important because breathing is a vital function. The patient decreases the risk of atelectasis and pneumonia after surgery with frequent coughing, deep breathing, incentive spirometry, and ambulation. A pain level of 2 is within normal limits for a postoperative patient requiring routine postoperative nursing care. The urine output is normal. Inaudible bowel sounds after major abdominal surgery on the first postoperative day would not be totally unexpected. They would require follow-up nursing interventions, but the respiratory system is priority.
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