Prevention Patrol
A post-op patient has been in bed most of the morning. What is one nursing action that helps prevent more than one complication?
Early ambulation. It helps reduce risk for DVT, pneumonia/atelectasis, constipation, ileus, and deconditioning.
A patient’s baseline heart rate has been in the 70s. Today it is 104. The patient says they feel “fine.” What should the nurse do?
Do not ignore the change. Reassess the patient, look for causes such as pain, anxiety, fever, dehydration, bleeding, hypoxia, or medication effects, and continue monitoring/escalate if needed.
A patient reports mild soreness after walking in the hall for the first time after surgery. Their vital signs are stable, and the pain improves with rest. Red flag or routine?
Routine, but the nurse should still assess pain, mobility tolerance, and safety.
A patient says, “I think I already took that medication this morning.” What should the nurse do before giving it?
Pause and clarify before administering. Check the MAR, ask follow-up questions, and verify with the appropriate nurse/provider if needed.
Which patient should the nurse see first?
A. A patient asking for a blanket
B. A fall-risk patient trying to get out of bed alone
C. A patient asking when lunch arrives
D. A patient requesting fresh water
B. The fall-risk patient trying to get out of bed alone because immediate safety comes first.
A patient has been sitting in the chair for several hours after surgery. Their heels are resting directly on the footrest, and they have limited ability to reposition themselves. What complication is the nurse trying to prevent?
Pressure injury. The nurse should offload pressure points, help the patient reposition, assess skin, and encourage mobility as tolerated.
A patient’s oxygen saturation is 88%, but the patient is talking comfortably. What should the nurse do first?
Assess the patient and verify the reading. Check probe placement, waveform if available, fingers/circulation, oxygen status, respiratory effort, and then intervene/escalate if the low reading is accurate.
A patient’s dressing has a small amount of old, dry drainage that was circled by the previous shift. There is no new drainage outside the marked area. Red flag or routine?
Routine. Continue to monitor the dressing and compare for changes.
A patient is scheduled to receive metoprolol. Their blood pressure is 94/58 and heart rate is 56. What is the safest nursing action?
Hold nothing independently without following policy, but do not give automatically. Check the order parameters, assess the patient, and notify/clarify before administration.
Which finding is more urgent?
A. Pain 4/10 after ambulation
B. New shortness of breath while resting
B. New shortness of breath while resting. Breathing concerns take priority.
A post-op patient is refusing to ambulate because of pain. What is the best nursing judgment?
Pain is a barrier to prevention. Assess pain, medicate if appropriate, allow time for medication to work, then attempt safe ambulation.
A patient’s abdomen is firm, distended, and painful after surgery. They also report nausea and have not passed gas. What complication is the nurse concerned about?
Possible post-op ileus or bowel obstruction. The nurse should keep assessing, monitor bowel sounds, nausea/vomiting, intake/output, pain, and escalate the finding.
A patient who was alert and oriented this morning is now confused, pulling at lines, and trying to get out of bed. Red flag or routine?
Red flag. This is an acute change in mentation and a safety risk. The nurse should assess and escalate.
A patient received an opioid 45 minutes ago. Now they are very drowsy, difficult to keep awake, and their respiratory rate is 9. What is the nurse most concerned about?
Opioid-related respiratory depression. The nurse should assess airway/breathing, oxygenation, sedation level, and escalate immediately.
The nurse enters a room and sees the IV pump alarming, the IV on the floor and a small amount of blood dripping off the patient's hand, the patient’s SCDs off, and the patient standing unsteadily while trying to reach the bathroom. What should the nurse address first?
Prevent the fall. Patient safety comes before the small amount of blood, IV pump or SCDs.
A patient is post-op day 1. They have hypoactive bowel sounds, mild abdominal distention, and are receiving opioids. What should the nurse anticipate?
Risk for constipation or developing ileus. The nurse should encourage ambulation, assess bowel function, monitor nausea/vomiting/distention, promote fluids if allowed, and review bowel regimen/orders.
A patient has new weakness on one side, slurred speech, and facial drooping. Their blood glucose is 62. What should the nurse recognize?
This could be hypoglycemia mimicking stroke, but stroke cannot be dismissed. Treat/check glucose per protocol and escalate immediately according to facility policy.
A patient reports new calf pain when walking. One calf appears larger than the other and is warm to the touch. Red flag or routine?
Red flag. The nurse should suspect possible DVT, avoid massaging the leg, limit unnecessary ambulation, assess further, and escalate.
A patient is receiving furosemide and reports new weakness. Their potassium is 3.1. What should the nurse recognize?
Possible hypokalemia related to diuretic therapy. This can increase risk for dysrhythmias and weakness, so the nurse should assess and escalate.
The nurse receives four updates at the same time. Which patient should the nurse assess first?
A. Patient with pain 8/10 who is requesting pain medication
B. Post-op day 1 patient whose heart rate increased from 84 to 112 over the last hour and says they feel “really tired”
C. Patient whose IV antibiotic just finished infusing
D. Patient who has not had a bowel movement in two days and is taking opioids
A post-op patient suddenly refuses to ambulate and says, “I just feel too weak today.” Their heart rate is 118, oxygen saturation is 91%, and one calf is more swollen than the other. What complication should the nurse suspect, and what is the safest nursing action?
Possible DVT with concern for PE risk. The nurse should stop ambulation, assess respiratory status and the extremity without massaging it, keep the patient safe, and escalate immediately.
A patient is one day post-op. Earlier vitals were BP 132/78, HR 84, RR 16. Current vitals are BP 96/58, HR 122, RR 24. The patient is pale, restless, and says they feel weak. The dressing has a small amount of new bright red drainage. What pattern should the nurse recognize?
Possible early shock or bleeding. The nurse should recognize the trend, not just one isolated vital sign. Stay with the patient, reassess vital signs, check the dressing/surgical site, assess mentation and skin signs, and escalate urgently.
A post-op patient says, “I just feel anxious and weird.” Their heart rate has increased from 82 to 116, oxygen saturation is 91%, and they report mild chest tightness. Their surgical pain is controlled. Red flag or routine, and what should the nurse be concerned about?
Red flag. The nurse should be concerned about possible pulmonary embolism or another acute change. The safest action is to assess respiratory status, keep the patient safe, stay with them if unstable, and escalate immediately.
A patient has sliding scale insulin due. Their blood glucose is 78, their breakfast tray has not arrived, and they say they feel shaky and sweaty. What is the safest nursing judgment?
This patient may be becoming hypoglycemic. The nurse should not give insulin automatically. Assess symptoms, follow hypoglycemia protocol/facility policy, make sure the patient receives carbohydrates if appropriate, recheck glucose, and escalate/clarify before giving insulin.
The nurse has four patients. Who should be seen first?
A. A patient with pain 8/10 requesting pain medication
B. A post-op patient who is suddenly more drowsy with a respiratory rate of 10
C. A patient waiting for discharge teaching
D. A patient with blood pressure 148/88 asking to shower
B. The post-op patient who is suddenly more drowsy with a respiratory rate of 10. This could indicate opioid oversedation, hypoxia, or acute deterioration. Airway and breathing concerns come before pain, teaching, or routine needs.