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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 D

Explanation

Rationale

A. Replace the NPWT dressing every 12 hours: NPWT dressings are typically changed every 48–72 hours, or sooner if the dressing is saturated or malfunctioning. Changing the dressing every 12 hours is excessive and can disrupt wound healing and increase infection risk.

B. Allow the wound to be open to air at least once per shift: Negative-pressure wound therapy requires a sealed environment to maintain suction and promote healing. Exposing the wound to air would compromise negative pressure, delay healing, and increase infection risk.

C. Shave the skin around the wound prior to applying the wound therapy device: Shaving can cause microabrasions and increase the risk of infection. Hair should be gently trimmed if necessary, but shaving is not recommended prior to applying NPWT dressings.

D. If client reports pain, decrease the suction to 75 mm Hg: Pain during NPWT can occur if suction pressure is too high. Reducing suction to 75 mm Hg helps minimize discomfort while maintaining therapeutic negative pressure. Adjusting suction appropriately promotes client comfort and adherence to therapy.

Correct Answer is D

Explanation

Rationale

A. Oral temperature 37.4° C (99.3° F): This temperature is within normal limits and does not indicate a concerning postoperative complication. Mild elevations can occur due to surgery or mild inflammatory responses, but this finding alone does not require provider notification.

B. BP 130/84 mm Hg: This blood pressure reading is slightly elevated but generally within acceptable postoperative limits. It does not indicate immediate risk from opioid therapy and does not necessitate urgent reporting.

C. Heart rate 88/min: A heart rate in the high-normal range is not unusual postoperatively and is not concerning in the context of opioid administration. Monitoring should continue, but this finding does not require immediate provider notification.

D. Respiratory rate 10/min: A respiratory rate below 12 breaths per minute is considered bradypnea and may indicate opioid-induced respiratory depression. This is a potentially life-threatening complication that requires immediate notification of the provider and prompt intervention to ensure adequate ventilation and oxygenation.

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