The nurse determines that the patient is at risk for atelectasis caused by pain from back surgery 3 hours ago. Which is the best goal for the nurse to help the patient achieve?

Question

a. The patient's lungs will be clear when auscultated every 2 hours.
b. The nurse will manage the patient's pain with oral morphine.
c. Cool the patient's elevated temperature with a cooling mat.
d. Maintain adequate cardiac output with a positive fluid balance.

Answer 1

A
Because of the cut back muscles, the patient is at risk for respiratory problems after surgery due to pain. The outcome reflects the patient's status and is stated in a manner that can be evaluated. The patient would benefit from intravenous morphine to manage pain because it is easier to con-trol. He or she can receive small, frequent doses for pain instead of a single, large dose that is more likely to result in hypotension. There is no indication for a cooling mattress. In addition, both of these are nursing interventions. For the patient at risk for alteration in cardiac output, maintaining a positive fluid balance increases the risk of fluid volume overload and can cause heart failure in the patient until the fluid is removed. The term adequate cannot be evaluated.