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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":"B","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • A nasogastric tube: The client is experiencing nausea, vomiting, abdominal distention, and absence of bowel sounds, which are indicative of a possible postoperative ileus or bowel obstruction. Inserting an NG tube will help to decompress the stomach, prevent further buildup of gastric contents, and reduce the risk of aspiration.
  • An antiemetic medication: The client is reporting nausea and vomiting, which can impede recovery and cause discomfort. Administering an antiemetic medication would help alleviate these symptoms, improve the client's comfort, and prevent complications like dehydration or electrolyte imbalances.

Rationale for Incorrect Choices:

  • An indwelling urinary catheter: There is no indication of urinary retention or output issues that would require an indwelling catheter. The client has an adequate urinary output (480 mL in 8 hours), the use of a catheter could increase the risk of urinary tract infections.
  • An oral airway: An oral airway is not necessary since the client is alert and oriented, with no signs of airway obstruction. The client is able to breathe adequately, and there is no indication of respiratory distress requiring airway support.
  • A bladder scan: The client is not experiencing urinary retention or issues with bladder function. The urinary output is adequate, so a bladder scan is unnecessary at this time.
  • Arterial blood gases: There is no indication of respiratory distress or acid-base imbalances that would require arterial blood gas analysis. The client's vital signs, including oxygen saturation and respiratory rate, are stable, and no signs of metabolic issues are present.


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Related Questions

Correct Answer is D

Explanation

A. Prop the feet up: Proping the feet up may not be effective in preventing plantar flexion contractures, as it does not provide sustained support to keep the feet in a neutral position. Plantar flexion can still occur with this position.

B. Apply an abduction pillow to the legs: An abduction pillow is used to keep the hips in a neutral position, not to prevent plantar flexion contractures. It is useful for preventing hip contractures but not specifically for the feet.

C. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip joint, not plantar flexion of the feet. It is used for positioning to prevent hip complications, but it does not address foot position or contracture prevention.

D. Use foot splints: Foot splints are designed to keep the feet in a neutral or dorsiflexed position, preventing the toes from pointing downward (plantar flexion). This is the most effective intervention to prevent plantar flexion contractures in an immobile client.

Correct Answer is C

Explanation

A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.

B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.

C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.

D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.

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