The nurse is caring for a client post-operatively following an open (incisional) cholecystectomy. Which would be the priority nursing intervention for this client?
Administer a narcotic analgesic every two hours.
Encourage a low-fat diet the first post-op day.
Encourage the use of the incentive spirometer.
Ambulate the client in the hall the first post-op evening.
The Correct Answer is C
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.
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Related Questions
Correct Answer is C
Explanation
A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.
Correct Answer is B
Explanation
A. Switching from regular to decaffeinated coffee does not significantly impact gastric cancer risk. The main dietary risk factors include high intake of salted, smoked, and processed foods, not caffeine consumption.
B. Consuming large amounts of salted, smoked, and processed foods has been shown to increase the risk of gastric cancer. These foods contain nitrates and nitrites, which can be converted into cancer-causing compounds in the stomach.
C. High-fiber diets are generally protective against gastrointestinal cancers, including gastric cancer, rather than increasing the risk. A reduction in fiber intake could contribute to other gastrointestinal problems.
D. Lactose intolerance is not a known risk factor for gastric cancer. Regular testing for gastric cancer is not necessary for people who are lactose-intolerant unless they have additional risk factors, such as a family history of gastric cancer.
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