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 

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and request a prescription for

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A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.

B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.

C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.

D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.

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.