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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 A

Explanation

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

Correct Answer is A

Explanation

A. "Do you snore loudly?": Loud snoring is a common symptom of sleep apnea, particularly obstructive sleep apnea. The nurse should inquire about snoring, as it may indicate airway obstruction during sleep, a key feature of the condition.

B. "What time do you go to bed?": While bedtime habits are relevant to sleep hygiene, the specific timing of going to bed is not as directly related to diagnosing sleep apnea. Other questions, such as snoring or breathing patterns, are more relevant for this assessment.

C. "How often do you have trouble sleeping?": Trouble sleeping can be a symptom of various sleep disorders, but it is not specific to sleep apnea. The nurse should focus on symptoms like snoring, choking, or stopping breathing during sleep, which are more indicative of sleep apnea.

D. "Do you fall asleep unexpectedly?": Falling asleep unexpectedly may suggest excessive daytime sleepiness, which can be a result of sleep apnea. However, snoring is a more direct and common symptom of sleep apnea that should be prioritized in the initial assessment.

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