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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 B

Explanation

A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.

B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.

C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.

D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.

Correct Answer is A

Explanation

A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.

B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.

C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.

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