The nurse has reviewed the Nurses' Notes and Vital Signs from Day 2 at 0430 and Provider Prescriptions from Day 1 at 2345.
Drag words from the choices below to fill in each blank in the following sentence.
The nurse should postoperatively assist the RN to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Rationale for correct choices:
• Assist with morphine 4 mg IV bolus: The client will likely experience postoperative pain following laparoscopic cholecystectomy. Assisting with the prescribed IV morphine helps manage pain effectively, improves comfort, and facilitates early mobilization and participation in postoperative care.
• Encourage use of a spirometer every hr while awake: Postoperative clients are at risk for atelectasis and pulmonary complications due to anesthesia and immobility. Encouraging frequent spirometer use promotes lung expansion, maintains adequate oxygenation, and reduces the risk of respiratory complications.
Rationale for incorrect choices:
• Place the client on their right side while in bed: This position is not routinely required after laparoscopic cholecystectomy; supine or semi-Fowler positions are typically recommended to optimize comfort and monitor for postoperative complications.
• Maintain the client on bed rest: Extended bed rest is not advised postoperatively. Early mobilization reduces the risk of venous thromboembolism, promotes bowel function, and accelerates recovery.
• Discontinue IV fluids: IV fluids are needed postoperatively to maintain hydration and electrolyte balance, particularly since the client is on NPO status until gastrointestinal function returns. Discontinuing fluids prematurely could lead to hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. One fingerbreadth of space between the cast and the skin: Adequate spacing indicates proper cast fit and helps prevent pressure sores, but it does not signal an immediate threat to circulation or tissue viability.
B. Ecchymosis on the inner left thigh: Mild bruising can occur from initial injury or cast application. While it should be monitored, it is not as urgent as compromised blood flow.
C. Diminished pulses on the affected extremity: Weak or absent pulses indicate impaired arterial circulation, which can lead to ischemia, tissue necrosis, or compartment syndrome. This finding requires immediate assessment and intervention to prevent permanent injury.
D. Client report of muscle spasms of the left leg: Muscle spasms can be uncomfortable but are typically not life- or limb-threatening. They are addressed after ensuring adequate circulation and neurovascular status.
Correct Answer is A
Explanation
A. Kussmaul respirations: Rapid, deep respirations can indicate metabolic acidosis, which may occur if the client develops fluid overload or electrolyte imbalances from IV sodium chloride infusion. Monitoring for respiratory changes helps identify early complications of aggressive fluid therapy in clients with hyperparathyroidism.
B. Chvostek's sign: This is a manifestation of hypocalcemia, not a typical adverse effect of sodium chloride infusion. Clients with hyperparathyroidism generally have elevated calcium levels, so Chvostek’s sign would be unlikely in this context.
C. Hyperthermia: Elevated body temperature is not a known complication of 0.9% sodium chloride infusion. Fever would more likely indicate infection or another unrelated process rather than a direct effect of IV therapy.
D. New onset of hearing loss: Hearing loss is not associated with isotonic saline administration. While severe hypercalcemia can rarely affect auditory function, normal IV sodium chloride therapy does not directly cause ototoxicity.
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