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A nurse is caring for a client who is 36 hr postoperative following an open cholecystectomy.

Exhibits

The nurse is planning care for the client.

Complete the following sentence by using the lists of options.

The nurse should prepare to insert 

and request a prescription for
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • A nasogastric tube: The client is experiencing nausea, vomiting, abdominal distention, and absence of bowel sounds, which are indicative of a possible postoperative ileus or bowel obstruction. Inserting an NG tube will help to decompress the stomach, prevent further buildup of gastric contents, and reduce the risk of aspiration.
  • An antiemetic medication: The client is reporting nausea and vomiting, which can impede recovery and cause discomfort. Administering an antiemetic medication would help alleviate these symptoms, improve the client's comfort, and prevent complications like dehydration or electrolyte imbalances.

Rationale for Incorrect Choices:

  • An indwelling urinary catheter: There is no indication of urinary retention or output issues that would require an indwelling catheter. The client has an adequate urinary output (480 mL in 8 hours), the use of a catheter could increase the risk of urinary tract infections.
  • An oral airway: An oral airway is not necessary since the client is alert and oriented, with no signs of airway obstruction. The client is able to breathe adequately, and there is no indication of respiratory distress requiring airway support.
  • A bladder scan: The client is not experiencing urinary retention or issues with bladder function. The urinary output is adequate, so a bladder scan is unnecessary at this time.
  • Arterial blood gases: There is no indication of respiratory distress or acid-base imbalances that would require arterial blood gas analysis. The client's vital signs, including oxygen saturation and respiratory rate, are stable, and no signs of metabolic issues are present.


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Related Questions

Correct Answer is A

Explanation

A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.

B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.

C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.

D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.

Correct Answer is C

Explanation

A. Milk the chest tube at least three times a day: Milking is generally not recommended as it can increase intrathoracic pressure and damage lung tissue. It should only be done with a provider’s order and specific indication.

B. Empty the drainage collection chamber when full: The collection chamber is a closed system and should not be emptied. When full, the entire drainage unit should be replaced to maintain sterility.

C. Ensure intermittent bubbling is present in the water seal chamber: Intermittent bubbling in the water seal chamber is expected during expiration or coughing, indicating air leaving the pleural space. However, continuous bubbling may suggest an air leak and requires evaluation.

D. Clamp the chest tube when transferring the client from bed to the chair: Clamping the tube is contraindicated during transport, as it can cause tension pneumothorax. The system should remain unclamped and below chest level.

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