The nurse is caring for a patient who underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy several hours ago. The highest priority for the nurse is to:

Question

1. Monitor blood pressure and pulse.
2. Assess the patient's acceptance of not being able to have children.
3. Teach the patient how to splint her abdomen while taking deep breaths.
4. Verify that the IV pump is working correctly.

Answer 1

1
Rationale 1: A postsurgical patient is at risk for internal bleeding at the site of the surgery. Monitoring blood pressure and pulse is necessary to verify that the patient is hemodynamically stable.
Rationale 2: Although this patient will not be able to become pregnant, because of the surgery, acceptance is a psychosocial issue and a lower priority.
Rationale 3: Splinting while deep-breathing is a comfort measure to facilitate oxygenation and prevent atelectasis, but this is not the highest priority.
Rationale 4: The patient needs IV fluids to replace blood loss during surgery and until oral intake is adequate, but this is not the highest priority.