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. A specific gravity within the normal range indicates adequate urine concentration and hydration status, which is not typically concerning.
B. This color is indicative of normal urine concentration and hydration status and is not necessarily indicative of urinary tract pathology.
C. Absence of glucose in the urine is a normal finding and does not typically warrant further investigation.
D. Microscopic hematuria (blood in the urine not visible to the naked eye) may indicate underlying urinary tract pathology, such as infection, inflammation, or kidney stones, and should be reported to the provider for further evaluation and management.
Correct Answer is B
Explanation
A. While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B. A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C. While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D. A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.
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