A client who is 6 hours post-op from a laparoscopic cholecystectomy reports difficulty breathing and sharp chest pain. What is the first action the nurse should take?
Administer the prescribed pain medication
Reposition the client to a semi-Fowler's position
Encourage deep breathing exercises and use of incentive spirometry
Assess the client's vital signs and oxygen saturation
The Correct Answer is D
A. While pain medication may be necessary, assessing the cause of symptoms takes priority before any intervention.
B. Repositioning may help improve lung expansion but should only be done after assessing the client’s status.
C. Incentive spirometry is important postoperatively but should follow an assessment to ensure safety.
D. The first priority is to assess vital signs and oxygen saturation to determine if the client is experiencing respiratory distress or a serious complication such as a pulmonary embolism or pneumothorax, which can present with chest pain and difficulty breathing after laparoscopic surgery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Client must be deemed mentally competent to make an informed decision – A valid surgical consent requires that the client has the mental capacity to understand the information provided and to make decisions regarding their care.
B. Can be made after morphine administration – Consent given after administration of sedatives or narcotics (e.g., morphine) is not valid, as these medications can impair judgment and cognition.
C. Can be made without consent if deemed emergent and the client is awake – If the client is awake and capable, consent must be obtained. Consent without client approval is only permissible in a true emergency when the client is unconscious or otherwise unable to consent, and no surrogate is available.
D. Must be given without coercion or pressure – Valid consent must be voluntary, meaning the client freely agrees without intimidation or manipulation.
E. A legally authorized representative may sign if the client is unable – If a client is incapacitated, a designated healthcare proxy or legal guardian can give consent on their behalf.
F. The nurse is responsible for explaining the procedure to the patient – It is the surgeon’s responsibility to explain the nature of the procedure, risks, benefits, and alternatives. The nurse’s role is to witness the consent and ensure the client understands, but not to provide the full procedural explanation.
Correct Answer is ["30"]
Explanation
Urine output less than 30 mL/hour for more than 2 consecutive hours is a sign of decreased kidney perfusion or possible renal impairment. It should be promptly reported to the provider to prevent further complications such as acute kidney injury. This threshold is a standard indicator used in clinical settings to monitor renal function and fluid balance.
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