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 A

Explanation

Ringing in ears. Furosemide is a loop diuretic, which can cause ototoxicity as an adverse effect, resulting in ringing in the ears, hearing loss, or vertigo. The nurse should instruct the client to monitor for these adverse effects and report them immediately if they occur.

An explanation for incorrect choices:

B. Metallic taste is a common adverse effect of metronidazole or clarithromycin, but not furosemide.

C. Rhinitis is associated with intranasal or occasionally oral corticosteroid use.

D. Agitation is a side effect for stimulants, sedatives, or antidepressants.

A. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. B. Remove the needle and release the tissue. C. Aspirate by pulling back on the plunger and inject the medication.

Correct Answer is A,C,B

Explanation

Here’s the correct sequence for administering ceftriaxone using the Z-track technique: 1. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. 2. Aspirate by pulling back on the plunger and inject the medication. 3. Remove the needle and release the tissue. This method helps to prevent the medication from leaking into the subcutaneous tissue, reducing irritation and discomfort.

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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

Explanation

Correct Answer is A,C,B

Explanation

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