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The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy.
He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.

Stat ventilation/perfusion (V/Q) of chest.

Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Stat 2 views chest x-ray.

Send sputum for culture & sensitivity stat.

Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Start the patient on antibiotic therapy.

Answer and Explanation

Correct Answer : B,C,E,F

B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Rationale:

Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:

Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.

Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.

Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.

Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.

Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.

C. Stat 2 views chest x-ray.

Rationale:

Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.

Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.

Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.

Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.

E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale:

CBC: Assesses for signs of infection or inflammation, including:

Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)

Anemia (low red blood cell count)

BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.

Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.

F. Start the patient on antibiotic therapy.

Rationale:

Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.

Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

While some individuals with Crohn's disease may find that avoiding gluten improves their symptoms, this is not a universal recommendation.

Gluten restriction is more often indicated for those with celiac disease or gluten sensitivity.

It's important to individualize dietary recommendations based on personal triggers and sensitivities.

Choice B rationale:

An elimination diet is a systematic approach to identifying foods that may trigger or worsen Crohn's disease symptoms.

It involves removing certain foods from the diet for a period of time, typically 2-4 weeks, and then gradually reintroducing them one at a time to observe any reactions.

This process can help individuals pinpoint specific foods that contribute to their symptoms and make informed dietary choices to manage their condition.

Choice C rationale:

There is no evidence to support a general restriction of calcium and iron in individuals with Crohn's disease.

In fact, these nutrients are essential for overall health and should be consumed in adequate amounts unless a specific deficiency or intolerance is identified.

Restriction of these nutrients could lead to nutritional deficiencies.

Choice D rationale:

Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease.

Maintaining adequate hydration is crucial for overall health, especially during flares when fluid loss through diarrhea may be increased.

Restricting fluids could potentially lead to dehydration and electrolyte imbalances.

A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines. D. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.

It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.

Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.

Choice B rationale:

Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.

PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.

Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.

It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.

The priority is to prevent further transmission by isolating the client.

Choice D rationale:

Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.

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Naxlex Comprehensive Predictor Exams

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is B

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

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