The practical nurse (PN) is caring for a client recovering from abdominal surgery. Which action should the PN take first?
A) Assess the client’s pain level.
B) Monitor cardiorespiratory status.
C) Provide an incentive spirometer.
D) Order supplies for a dressing change.
The correct answer and explanation is:
The correct answer is B) Monitor cardiorespiratory status.
In the immediate postoperative period, the most critical priority is ensuring the client’s cardiorespiratory stability. Following abdominal surgery, patients are at risk for complications such as respiratory distress, hypoxia, and cardiovascular instability, particularly due to the effects of anesthesia, the pain from the surgery, and potential fluid imbalances. Assessing and monitoring the cardiorespiratory status allows the nurse to detect any early signs of complications like respiratory depression, arrhythmias, or hypovolemic shock.
Monitoring the cardiorespiratory status includes checking vital signs such as heart rate, respiratory rate, blood pressure, oxygen saturation, and listening for abnormal breath sounds like crackles or wheezing. These parameters can help identify problems like atelectasis, pulmonary embolism, or fluid overload, all of which can pose significant risks after surgery.
Once the cardiorespiratory status is stable, other actions can be taken in the following order of priority. Assessing the client’s pain level (option A) is crucial for comfort, but managing respiratory function takes precedence. Providing an incentive spirometer (option C) is also important for preventing complications like pneumonia, as it encourages deep breathing and lung expansion, but it is more beneficial once the patient’s cardiorespiratory status is stabilized. Ordering supplies for a dressing change (option D) is necessary but can wait until the patient is stable.
In summary, the first action the practical nurse should take is to monitor the cardiorespiratory status to ensure the client is not experiencing any immediate complications that could jeopardize their recovery. Once respiratory and cardiovascular stability is achieved, the nurse can then move on to addressing pain management, lung function, and wound care.