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

Answer and Explanation

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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Correct Answer is B

Explanation

A. While nausea and vomiting are common side effects of many chemotherapy agents, this is not specific to vesicants, which are drugs that can cause tissue damage if they leak outside the vein.
B. Vesicant chemotherapy agents can cause severe tissue damage, necrosis, and ulceration if they extravasate (leak into surrounding tissue). Close monitoring of the IV site for signs of redness, swelling, or pain is essential.
C. This may indicate gastrointestinal or bladder irritation from other types of chemotherapy agents, but it is not the hallmark concern with vesicants.
D. This is unrelated to vesicant properties. Orthostatic hypotension may occur from dehydration or autonomic effects, but not from vesicant infiltration.

A. Administer an antibiotic per orders. B. Offer a warm sitz bath. C. Recommend drinking cranberry juice. D. Encourage decreasing oral fluids.

Correct Answer is A

Explanation

A. Treating the infection promptly with antibiotics is the highest priority in managing a UTI. This helps eliminate the causative bacteria, reduce symptoms, and prevent complications like pyelonephritis or sepsis.

B. Offering a warm sitz bath is helpful but not priority. While this may relieve discomfort or dysuria, it does not treat the underlying infection.

C. Cranberry juice may help prevent future UTIs but does not treat active infections.

D. Clients with a UTI should be encouraged to increase fluid intake, not decrease, to help flush out bacteria from the urinary tract.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient receiving a chemotherapy agent that is a vesicant should be monitored for which adverse effect?

Correct Answer is B

Explanation

A nurse is caring for a client who has a urinary tract infection (UTI). Which intervention is of highest priority while caring for the client? Select one:

Correct Answer is A

Explanation

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