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

Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.

Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.

Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.

Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.

A. Inactivated polio virus B. Herpes zoster C. Human papilloma virus D. Measles, mumps, and rubella

Correct Answer is B

Explanation

The correct answer is choice B, herpes zoster. A 65-year-old client should receive the herpes zoster vaccine, which is recommended for adults over the age of 60 years to prevent shingles. Choice A is incorrect because inactivated polio virus vaccine is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus. Choice C is incorrect because the human papillomavirus vaccine is recommended for females aged 9-26 years and males aged 9-21 years. Choice D is incorrect because the measles, mumps, and rubella vaccine is recommended for individuals born after 1957 who have not had the vaccine or the diseases.

Choice A: Inactivated polio virus vaccine is incorrect because it is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus.

Choice C: Human papillomavirus vaccine is incorrect because it is recommended for females aged 9-26 years and males aged 9-21 years.

Choice D: Measles, mumps, and rubella vaccine is incorrect because it is recommended for individuals born after 1957 who have not had the vaccine or the diseases.

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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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Explanation

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Correct Answer is B

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