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A nurse is caring for a client who is 36 hr postoperative following an open cholecystectomy.

Exhibits

The nurse is planning care for the client.

Complete the following sentence by using the lists of options.

The nurse should prepare to insert

and request a  prescription for .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Rationale for Correct Choices

  • Nasogastric tube: The client is experiencing nausea, vomiting, abdominal distension, firm abdomen, hypoactive/absent bowel sounds, and has not passed flatus since surgery, indicating possible postoperative ileus or gastric distension. Inserting a nasogastric tube can help decompress the stomach, relieve nausea, and prevent further complications such as aspiration.
  • Opioid analgesic: The client reports increased incisional pain (5/10) and discomfort associated with abdominal distension. Administering an opioid analgesic as prescribed helps manage pain, allowing for comfort, mobility, and participation in postoperative care.

Rationale for Incorrect Choices

  • Chest tube: Chest tubes are used to drain air, blood, or fluid from the pleural space and are not indicated for abdominal distension or postoperative ileus. Additionally, the clients lung sounds are normal with adequate saturation on supplementary oxygen.
  • Urinary catheter: The client’s urinary output is adequate (480 mL in 8 hr),averaging 60 mL/hr so a urinary catheter is not necessary at this time and does not address abdominal distension or nausea.
  • Antibiotics: There is no evidence of infection at this time. Prophylactic or therapeutic antibiotics are not indicated solely for postoperative pain or nausea without signs of infection.
  • Antihypertensive: The client’s blood pressure (104/68 mm Hg) is slightly lower than earlier but does not warrant antihypertensive therapy. Administering such medication could worsen hypotension and perfusion.


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Related Questions

Correct Answer is C

Explanation

Rationale

A. "You should use woolen blankets on your bed.": Woolen or synthetic blankets can generate static electricity, which increases the risk of fire when oxygen is in use. Clients should use cotton or other nonstatic materials to reduce this hazard.

B. "You will no longer be able to use an electric razor.": Electric razors are safe for use with home oxygen because they do not produce sparks. There is no need to prohibit their use; in fact, electric razors are recommended over safety razors to prevent cuts.

C. "You should purchase a fire extinguisher for your home.": Having a fire extinguisher readily available is an important safety precaution when oxygen is used at home. Oxygen supports combustion, so being prepared for emergencies reduces the risk of serious injury or property damage.

D. "Family members who smoke must do so at least 6 feet away from the oxygen tank.": Smoking should be prohibited entirely in areas where oxygen is in use. There is no safe distance for smoking near an oxygen source, and even a six-foot distance does not eliminate the fire risk. Strict no-smoking policies are essential.

Correct Answer is A

Explanation

Rationale

A. "I will be available for you until your family arrives.": This response provides emotional support and reassurance, addressing the client’s anxiety about undergoing the procedure alone. It demonstrates presence, empathy, and commitment to the client’s safety and comfort.

B. "I'm sure your family will be here soon.": This statement offers false reassurance because the nurse cannot guarantee the family’s arrival time. It may minimize the client’s feelings and does not provide immediate emotional support.

C. "You'll feel better once this procedure is over.": This focuses on the outcome rather than the client’s current emotional distress. It may invalidate the client’s feelings and does not offer support in the present moment.

D. "Why do you think your family is delayed?": Asking “why” can seem judgmental or accusatory and may increase the client’s anxiety. It does not provide comfort or address the immediate need for support before the procedure.

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