Question

A post-operative client with an abdominal wound who is receiving intravenous fluids infusing at 125 mL/hr returned to the unit six (6) hours ago. Which nursing interventions should the nurse add to the plan of care? Mark all that apply.

a. Assess pain to prevent post-operative complications.
b. Monitor labs to assess the client's physiologic response to surgery.
c. Maintain TED hose at all times to prevent blood clots.
d. Monitor intake and output to prevent fluid imbalances.
e. Encourage the use of the incentive spirometer to prevent pneumonia.

Answer 1

The nurse should assess pain, monitor labs, monitor intake and output, and encourage the use of the incentive spirometer for a post-operative client with an abdominal wound receiving intravenous fluids. TED hose does not need to be maintained in this case.

Step-by-step explanation:

The nurse should add the following nursing interventions to the plan of care for the post-operative client with an abdominal wound receiving intravenous fluids:

1. Assess pain to prevent post-operative complications. This involves regularly assessing the client's pain level and providing appropriate pain management interventions.
2. Monitor labs to assess the client's physiologic response to surgery. This involves monitoring laboratory values such as complete blood count, electrolytes, and blood glucose to ensure the client's body is functioning appropriately.
3. Monitor intake and output to prevent fluid imbalances. This involves accurately measuring and documenting the client's fluid intake (from intravenous fluids, oral intake, etc.) and output (urine, drainage, etc.) to identify any imbalances.
4. Encourage the use of the incentive spirometer to prevent pneumonia. This involves teaching the client to use the incentive spirometer to improve lung function and prevent respiratory complications.

The nursing interventions of maintaining TED hose at all times to prevent blood clots is not necessary in this case. While TED hose can help prevent blood clots, it is not specifically indicated for a post-operative client with an abdominal wound receiving intravenous fluids.