A nurse is caring for a client who is postoperative following a laparoscopic cholecystectomy. Which of the following actions should the nurse take?
Remove the abdominal dressings on the day of surgery.
Encourage ambulation on the day of surgery.
Place the client in a supine position postoperatively.
Offer the client ice cream postoperatively.
The Correct Answer is B
A. Dressings are typically not removed on the day of surgery to allow for observation of any bleeding or drainage. Dressing removal is usually performed by the surgical team or as directed by the healthcare provider.
B. Encourage ambulation on the day of surgery: Ambulation is important for preventing complications such as deep vein thrombosis and atelectasis, and to promote healing.
C. Postoperative positioning depends on the type of surgery performed and any specific patient needs, but placing the client in a supine position may not address comfort or respiratory considerations.
D. Offering ice cream, which is high in fat, may not be tolerated well immediately after this type of surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tight fitting clothes may put pressure on the T-tube insertion site and interfere with drainage. Loose-fitting clothing is recommended.
B. Showering is typically preferred over baths to keep the T-tube site clean and dry.
Baths may increase the risk of infection.
C. Regular emptying of the drainage bag helps prevent excessive weight, which can pull on the T-tube and cause discomfort or displacement. However, it should necessarily be emptied at the same time each day.
D. Securing the tubing to clothing helps prevent accidental dislodgment or pulling on the T-tube, reducing the risk of complications.
Correct Answer is C
Explanation
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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