A nurse is assisting with the care of a client on a medical surgical unit who was admitted from the emergency department.

Exhibits

For each assessment finding on Day 2 click to specify if the finding is due to lisinopril, carvedilol, or furosemide. Each finding may be related to more than 1 medication.

A. "I should eat a high-fat diet for several weeks." After a laparoscopic cholecystectomy, clients are typically advised to follow a low-fat diet for several weeks to help their bodies adjust to the absence of the gallbladder. The gallbladder stores bile, which aids in the digestion of fats. Without it, a high-fat diet can lead to gastrointestinal discomfort, including cramping and diarrhea. Gradually reintroducing fats based on tolerance is recommended.
B. "I should expect to have diarrhea until my diet changes." While some clients may experience temporary diarrhea after surgery, it is not a universal side effect. Changes in bowel habits can occur due to alterations in bile flow, but not all clients will have diarrhea. Maintaining a balanced diet and gradually increasing fiber intake can help regulate bowel movements and minimize gastrointestinal disturbances.
C. "I should leave my steri-strips on until they fall off." Steri-strips, or adhesive strips used to secure the incision, should be left in place until they naturally fall off, which usually occurs within one to two weeks. Removing them prematurely can compromise the healing process and increase the risk of infection or wound dehiscence.
D. "I should expect to have nausea for several days." Nausea can occur after surgery due to anesthesia, but it should not persist for several days. While some postoperative nausea is normal, ongoing or severe nausea may indicate a complication, such as an adverse reaction to medication or an underlying issue, and should be communicated to the healthcare provider for further evaluation and management.

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.