The nurse is caring for a client 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 client's acceptance of not being able to have children.
3. Teach the client how to splint her abdomen while taking deep breaths.
4. Verify that the IV pump is working correctly.

Answer 1

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