A nurse is caring for a patient who has had major abdominal surgery. The postsurgical nurse is aware that the postoperative plan of care should include:
A) Providing passive range of motion, assisting the patient with coughing and deep breathing as needed, and increasing mobility by helping the patient sit on the side of the bed every day.
B) Assessing bowel sound every 8 hours, offering medications as ordered, and allowing the patient privacy and security.
C) Managing the patient's pain, working with the patient to cough and deep breathe every 2 hours, turning the patient frequently, exercising, and ambulating as early as possible.
D) Allowing the patient to visit with family, allowing time for rest and reflection, and then have the nursing assistant provide a sponge bath while the nurse begins the discharge teaching process.
Ans: C
Feedback: Postsurgical patients need to cough and deep breathe to expel the remaining anesthesia. Pain management allows the patient to increase activity. With major abdominal surgery, distention can be avoided by having the patient turn frequently, exercise, and ambulate as early as possible. Option A is incorrect; providing passive range of motion is only used when patients are unable to move body parts for themselves, which would not be the case for a patient who has had abdominal surgery. Assisting the patient with coughing and deep breathing is important; helping the patient sit on the side of the bed should be followed by standing and a short walk on postoperative day one. Option B is incorrect; assessing bowel sounds, providing medications as ordered, and allowing patient privacy and security are all important but they are not the key postsurgical assessments and interventions. Option D is incorrect; allowing the patient to visit with family is important but patient stays in the hospital are short and self-care activity is critical for patient success. Instructing the nursing assistant to provide a sponge bath does not promote self-care. If the patient is not mobile, discharge teaching will be unnecessary.
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