A nurse is planning to complete an incisional dressing change for a client who is postoperative following an open cholecystectomy, in which of the following areas should the nurse expect to find the client's incision? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
D
None
None
The Correct Answer is A
A. Right upper quadrant of the abdomen: An open cholecystectomy involves surgical removal of the gallbladder, which is located in the right upper quadrant beneath the liver. The incision is typically made just below the right rib cage, making area A the correct site for the dressing change.
B. Midline of the upper abdomen: This area corresponds to the epigastric region and would not align with the typical location for a gallbladder incision. Incisions here are more common for other abdominal surgeries, such as exploratory laparotomy.
C. Lower midline abdomen: This area is associated with procedures involving the lower gastrointestinal tract, such as appendectomy or hysterectomy, and is not consistent with a cholecystectomy incision.
D. Right lower quadrant: This region is typically related to surgeries involving the appendix, cecum, or right ovary, not the gallbladder. Selecting this area would not correspond to the correct postoperative site for a cholecystectomy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fundus is located 2 cm (0.4 in) below the level of the umbilicus: A fundus slightly below the umbilicus 24 hours postpartum is expected as the uterus involutes. This is a normal finding and does not require immediate reporting unless accompanied by excessive bleeding or other concerning signs.
B. Scant lochia rubra on the perineal pad: Scant lochia rubra is typical within the first 24 hours postpartum, indicating normal uterine shedding. It is expected and does not indicate a complication in the absence of heavy bleeding or foul odor.
C. Non-pitting bilateral peripheral edema: Mild non-pitting edema in the lower extremities can occur postpartum due to fluid shifts and is usually self-limiting. It is not typically emergent unless accompanied by severe swelling, pain, or signs of deep vein thrombosis.
D. Oral temperature of 38.8° C (101° F): An elevated temperature above 38° C 24 hours postpartum may indicate infection, such as endometritis or urinary tract infection. This finding requires immediate reporting to the RN for further assessment and intervention.
Correct Answer is C
Explanation
A. Chloasma: Chloasma refers to hyperpigmented patches on the face, often called the "mask of pregnancy." It is a skin change due to hormonal fluctuations and does not involve the coloration of the vagina or vulva.
B. Ballottement: Ballottement is a technique used during a prenatal exam to detect a floating fetus by tapping the cervix, resulting in a rebound sensation. It is not related to changes in vaginal or vulvar color.
C. Chadwick's sign: Chadwick's sign is the bluish-purple discoloration of the cervix, vagina, and vulva that occurs around 6–8 weeks of gestation due to increased vascular congestion. This is the correct documentation for the observed purplish coloration.
D. Hegar's sign: Hegar's sign is the softening of the lower uterine segment, which can be palpated during early pregnancy. It is a physical finding of the uterus, not a visual change of the vaginal or vulvar tissues.
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