A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?

Report of shoulder pain

Thick, green-brown drainage on dressing

Incisional pain 5 out of 10 on a pain scale

Abdominal dressing dry and intact

Answer and Explanation

The Correct Answer is B

This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.

Choice A, reporting of shoulder pain, is not the correct answer because this is a common finding post-cholecystectomy, which is often due to the presence of carbon dioxide used during the surgical procedure.

Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.

Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.

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Correct Answer is C

Explanation

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

A. Recent exposure to tuberculosis B. History of generalized anxiety disorder C. Reports periodic migraine headaches D. Experiences nocturia E. Experiences nocturia

Correct Answer is A

Explanation

Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.

Reasons why the other options are not answers:

Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.

Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.

Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.

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A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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