A nurse is caring for a 58-year-old client who underwent a radical nephrectomy for renal cell carcinoma 24 hours ago. The client has a large abdominal incision with surgical drains in place. Which nursing intervention is the priority during the immediate postoperative period?
1Encourage early ambulation to prevent deep vein thrombosis
2Monitor urine output from the urinary catheter every 2 hours
3Assess the surgical incision for signs of infection
4Monitor respiratory status and encourage deep breathing exercises✓ 정답
해설
Monitoring respiratory status and encouraging deep breathing exercises is the priority due to the risk of respiratory complications like atelectasis or pneumothorax from the surgical site's proximity to the diaphragm. Other interventions are important but secondary to preventing life-threatening respiratory failure.
Core Nursing ExplanationKey Concept Analysis: This question asks you to determine the priority nursing intervention for a patient in the immediate postoperative period after a radical nephrectomy. The core theme is applying the ABC (Airway, Breathing, Circulation) priority framework. After major abdominal surgery, especially one involving the upper abdomen near the diaphragm, the greatest immediate risk is respiratory compromise due to pain, anesthesia, and immobility, leading to atelectasis (lung collapse) and hypoxemia.
Answer Rationale: Key Point! The correct answer is ④ Monitor respiratory status and encourage deep breathing exercises. This directly addresses the Airway and Breathing components of the ABCs, which are always the highest priority. A radical nephrectomy involves a large flank or abdominal incision, which causes significant pain that inhibits deep breathing and coughing. This, combined with the effects of general anesthesia and opioid analgesics, significantly increases the risk of postoperative atelectasis and pneumonia. Early and aggressive pulmonary hygiene (deep breathing, coughing, incentive spirometry) is essential to prevent these life-threatening complications.
Distractor Analysis:
Watch out for confusion!① Encourage early ambulation to prevent deep vein thrombosis (DVT): While early ambulation is a crucial postoperative intervention to prevent DVT and promote overall recovery, it is not the immediate priority in the first 24 hours. Airway and breathing always come before mobility. Ambulation is typically initiated once the patient is stable from a respiratory and circulatory standpoint.
Watch out for confusion!② Monitor urine output from the urinary catheter every 2 hours: This is a very important intervention specific to a nephrectomy patient, as it assesses the function of the remaining kidney. However, it falls under the "Circulation" and "Elimination" components. While critical, a problem with urine output (e.g., oliguria) would not be as immediately life-threatening in the first minutes to hours as respiratory failure.
Watch out for confusion!③ Assess the surgical incision for signs of infection: Incision assessment is important for monitoring for hemorrhage, dehiscence, or infection. However, signs of infection (redness, warmth, purulent drainage) typically develop over days, not in the immediate 24-hour postoperative period. Monitoring for acute bleeding is part of circulatory assessment, which follows airway and breathing.
Related Concepts: The nursing process requires prioritization based on Maslow's Hierarchy of Needs and the ABCs. Physiological needs (airway, breathing) must be met before safety needs (preventing DVT, monitoring infection). This question tests the ability to apply this fundamental principle to a specific surgical scenario.
Concept Summary
Concept
Description
Application in This Scenario
ABC Priority
Airway, Breathing, Circulation. The foundational framework for assessing and prioritizing patient care.
Ensuring adequate ventilation and oxygenation is always the first priority after surgery.
Postoperative Atelectasis
Collapse of lung alveoli due to shallow breathing, often caused by surgical pain and anesthesia.
The large abdominal incision causes splinting (shallow breathing to avoid pain), making deep breathing exercises the priority intervention.
Radical Nephrectomy
Surgical removal of a kidney, surrounding fat, adrenal gland, and nearby lymph nodes, typically for renal cell carcinoma.
Involves a large incision with significant pain and risk of affecting diaphragm movement, heightening respiratory risk.
Nursing Process: Prioritization
Determining the order of nursing actions based on patient urgency and need.
Even with multiple important tasks (urine output, ambulation, incision care), life-sustaining functions (breathing) come first.
ABC framework. Hypoxemia can lead to cardiac arrest within minutes. DVT risk increases over days.
Circulation (Vital signs, bleeding assessment)
Incision Care for Infection
Acute hemorrhage is an immediate circulatory threat. Infection signs develop later.
Pain Management (To facilitate breathing)
Full Nutritional Intake
Uncontrolled pain inhibits breathing. Nutrition is important for healing but is a lower-level need initially.
Anatomy, Physiology & Pharmacology Points
Anatomy: The kidneys are retroperitoneal organs located high in the abdominal cavity, near the diaphragm. A flank incision for nephrectomy can directly irritate the diaphragm and intercostal muscles, contributing to respiratory splinting.
Physiology: General anesthesia suppresses the respiratory drive and ciliary function in the lungs. Opioid analgesics (e.g., morphine) further depress respiratory rate and depth. This combination makes proactive pulmonary care non-negotiable.
Pharmacology: Patient-controlled analgesia (PCA) with opioids is common post-op. Nurses must monitor for Key Point!respiratory depression (rate < 12/min, sedation) while ensuring pain is controlled enough for the patient to take deep breaths.
Memory Tips
ABCs Rule: "Always Breathe Clearly" before doing anything else post-op.
Mnemonic for Post-Op Priorities: "Breathe, Bleed, Beats, Bag (Urine), Bowels, Bones (Ambulation)". This lists priorities in order: Breathing, Bleeding, Circulation (Heart beats), Urinary output, Bowel function, then Mobility.
Think: "If the patient can't breathe, nothing else matters."
High-Frequency NCLEX Topics
Prioritization questions using the ABC framework are extremely common on the NCLEX-RN. The exam often presents a patient with multiple needs (e.g., post-op, trauma, medical emergency) and asks, "Which action should the nurse take first?" or "What is the priority?" Always scan the options for actions that directly address an airway obstruction, ineffective breathing, or absent circulation.
Watch Out for Question Variations!
Variation 1 (Shift in Priority): "The nurse assesses the postoperative nephrectomy client and finds absent breath sounds on the left side with tracheal deviation to the right. What is the priority action?" (Answer: This suggests a tension pneumothorax—a medical emergency. The priority would be to prepare for chest tube insertion, not just encourage deep breathing.)
Variation 2 (Change in Timeframe): "On postoperative day 3, the client has a normal respiratory rate and is ambulating. The nurse notes the urinary catheter output has been 20 mL/hr for the past 2 hours. What is the priority?" (Answer: Now, oliguria and assessment of the remaining kidney function become the priority, as the immediate respiratory threat has passed.)
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a surgical unit. Mr. Johnson, 58, is 24 hours post-op from a left radical nephrectomy. He is on a morphine PCA pump, has a urinary catheter, two Jackson-Pratt (JP) drains near his incision, and oxygen at 2 L/min via nasal cannula. He is drowsy but arousable and reports his pain as 7/10 when he takes a deep breath.
Nursing Intervention Strategy:
Assessment (Every 1-2 hours initially):
Respiratory: Rate, depth, rhythm, oxygen saturation (SpO2), lung sounds in all lobes. Use a incentive spirometer and have the patient demonstrate its use. Observe for splinting (holding the incision).
Pain: Assess using a numeric scale, especially before encouraging deep breathing/coughing. Pre-medicate if needed per protocol.
Circulatory/Renal: Monitor vital signs, assess incision and drains for bleeding, measure urine output hourly.
Implementation - Priority Actions:
Facilitate Breathing: Coach the patient to use the incentive spirometer 10 times every hour while awake. Assist with splinting the incision (using a pillow) during coughing. Ensure adequate analgesia to allow for deep breaths.
Positioning: Elevate the head of the bed (HOB) to at least 30-45 degrees to maximize lung expansion.
Monitor and Act: If respiratory rate drops below 12 or SpO2 falls below 92%, stimulate the patient, consider withholding the next PCA dose, and notify the provider. Be prepared for possible nebulizer treatments or increased oxygen.
Patient Safety and Precautions:
PCA Safety: Only the patient should press the button. Monitor for excessive sedation. Have naloxone (Narcan) available per facility policy.
Drain Care: Maintain suction on JP drains, monitor character and volume of output (serosanguinous is expected). Sudden bright red output or large volume increase could indicate bleeding.
Ambulation: Once the patient is hemodynamically stable and breathing well, collaborate with physical therapy to ambulate. This helps prevent DVT and improves lung expansion.
Nursing Procedure & Medication FlowDeep Breathing & Coughing / Incentive Spirometry Procedure:
1. Explain the purpose (prevent pneumonia, expand lungs).
2. Ensure adequate pain relief (administer analgesic 30 min prior if needed).
3. Assist patient to High-Fowler's or sitting position.
4. For deep breathing: Instruct to inhale slowly and deeply through the nose, hold for 2-3 seconds, exhale slowly through pursed lips. Repeat 5-10 times.
5. For coughing: After a deep breath, instruct to cough deeply 2-3 times while splinting the incision with a pillow or hands.
6. For incentive spirometry: Instruct to seal lips around mouthpiece, inhale slowly to raise the ball/cylinder, hold for 2-3 seconds, then exhale normally. Document volume achieved.
Opioid Analgesia (e.g., Morphine PCA) Monitoring:
- Assess Respiratory Rate, Sedation Level, and Pain Score before initiating and at least every 1-2 hours thereafter.
- Use a sedation scale (e.g., Pasero Opioid-Induced Sedation Scale). If the patient is somnolent with minimal response to stimuli, hold the medication and notify the provider.
- Monitor for other side effects: nausea/vomiting, constipation, urinary retention.
A Word from Your Senior Nurse
"Remember, in the immediate post-op phase, your patient's lungs are your primary battlefield. That drowsy, pain-medicated patient isn't being lazy—their body is being suppressed by powerful drugs and trauma. It's your vigilant assessment and proactive encouragement of those deep breaths and coughs that keep their airways open and prevent a cascade of complications. Don't just chart 'incentive spirometer at bedside.' Get in there, coach them, cheer them on, and splint that incision for them. That's the difference between a textbook answer and truly excellent, life-sustaining nursing care. Carry this ABC mindset into every clinical situation, and you'll be a safe and effective nurse from day one."
Atelectasis — Collapse or closure of a lung resulting in reduced or absent gas exchange. A common postoperative complication due to shallow breathing.
Incentive Spirometry — A device used to encourage voluntary deep breathing by providing visual feedback. It is a key nursing intervention to prevent atelectasis.
Radical Nephrectomy — Surgical removal of a kidney, the adrenal gland, surrounding tissue, and often nearby lymph nodes, typically performed for renal cell carcinoma.
ABC Priority — A fundamental nursing and emergency care framework that establishes the order of assessment and intervention: Airway, Breathing, Circulation.
Oliguria — Low urine output, typically defined as less than 400 mL per day or less than 0.5 mL/kg/hr. A critical finding to monitor after nephrectomy.