The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?
Determine when the client last had pain medication.
Offer to assist the client to the restroom to void.
Review postoperative instructions with the client.
Confirm that the client has been NPO since midnight.
The Correct Answer is D
NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.
It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.
While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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A. Discuss with provider → Correct. The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
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B. Side effects dissipate → Incorrect. Some antidepressant side effects improve, but others persist. This statement minimizes the client’s concerns and is not therapeutic.
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C. Gradual tapering → Incorrect. While tapering is necessary, the nurse should not instruct discontinuation independently. This is the provider’s role.
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D. Feeling better is therapeutic effect → Incorrect. Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
Correct Answer is C
Explanation
A) Incorrect- The left lateral position might not provide enough lung expansion for a client in respiratory distress.
B) Incorrect- Reverse Trendelenburg (head of bed elevated, foot of bed lowered) might not provide enough lung expansion and could exacerbate respiratory distress.
C) Correct- The High-Fowler's position, where the client is sitting upright at a 90-degree angle or as upright as tolerated, helps to improve lung expansion, reduce pressure on the diaphragm, and promote optimal oxygenation. This position is commonly used for clients with respiratory distress.
D) Incorrect- The supine position may worsen pulmonary congestion and compromise lung expansion in clients with pulmonary edema.
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