Scenario

You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction (LIS). The client has a history of smoking and no other health problems.

Vital signs:

Temperature: 99.2° F
Heart rate: 91 beats/min
Respirations: 20 breaths/minute
O2 saturation: 93% on 2L oxygen via nasal cannula
Blood pressure: 110/68 mm Hg
Pain: “6/10”
Focused assessment findings:

Alert and oriented to person, place, and time
Moves all four extremities, refuses to ambulate
Apical pulse is regular at 91 beats/minute
Lungs diminished bilaterally in the bases
Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
Instructions