A nurse is caring for an adolescent.
Admission Assessment 1400:
Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in . their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.
Which of the following actions should the nurse take after the adolescent returns from surgery?
Select all that apply.
A.
Remove indwelling urinary catheter when no longer indicated
B.
Elevate affected limb at chest level
C.
Assist the adolescent with ambulation from bed to chair
D.
Perform neurovascular assessments every hour
E.
Apply warm packs to right extremity for the first 24hrs
The Correct Answer and Explanation is:
The correct answers are A. Remove indwelling urinary catheter when no longer indicated, B. Elevate affected limb at chest level, and D. Perform neurovascular assessments every hour.
Here’s a detailed explanation for each choice:
A. Remove indwelling urinary catheter when no longer indicated
Explanation: After surgery, an indwelling urinary catheter is often used to monitor urine output and ensure the bladder remains empty while the patient is immobilized. However, once the adolescent’s condition stabilizes and they are able to void independently, the catheter should be removed to reduce the risk of infection and promote normal bladder function. It is important to remove it when it is no longer needed.
B. Elevate affected limb at chest level
Explanation: Elevation of the affected limb is crucial for reducing edema and promoting venous return. Keeping the limb elevated to the level of the chest helps to minimize swelling by utilizing gravity to assist in fluid return. However, it is important to monitor the position to avoid pressure on the surgical site and ensure it is not excessively high, which could affect circulation.
D. Perform neurovascular assessments every hour
Explanation: Frequent neurovascular assessments are essential in monitoring for signs of complications such as compartment syndrome or compromised circulation in the affected limb. These assessments include checking for color, temperature, pulse, capillary refill, and sensation in the limb. Performing these assessments every hour helps in early detection of any issues that may arise postoperatively and ensures timely intervention.
Incorrect Choices:
C. Assist the adolescent with ambulation from bed to chair Explanation: Initially, the adolescent should be assisted with ambulation only after the surgical site is stable and the healthcare provider has cleared them for movement. Post-surgery, especially with a recent fracture or major surgery, mobility is typically restricted to prevent complications. Early ambulation can be considered later in the recovery process when the patient is deemed stable and capable of safely moving.
E. Apply warm packs to right extremity for the first 24 hours Explanation: Applying warm packs to the surgical site is generally not recommended immediately after surgery. Cold therapy is typically used during the first 24-48 hours post-surgery to reduce inflammation and numb the area, which helps to control pain and swelling. Warm packs can be used later in the recovery process to promote blood flow and aid in muscle relaxation, but initially, cold therapy is preferred.
Overall, post-surgical care focuses on monitoring for complications, managing pain, and supporting recovery. The selected actions align with these goals, ensuring the adolescent’s safe and effective recovery from surgery.