A nurse is caring for a client who is postoperative following a cholecystectomy and reports incisional pain. Which of the following actions should the nurse take?

Encourage the client to ambulate every 4 hours

Administer a prescribed analgesic

Apply a warm compress to the incision

Instruct the client to avoid deep breathing

Answer and Explanation

The Correct Answer is B

Choice A reason: Ambulation every 4 hours prevents complications like thrombosis but does not directly relieve incisional pain. Analgesics address pain immediately, making ambulation a secondary intervention.

Choice B reason: Administering a prescribed analgesic directly relieves incisional pain, improving comfort and recovery. Pain management is a priority post-cholecystectomy, making this the correct action for the nurse to take.

Choice C reason: A warm compress may increase bleeding or swelling at the incision site. Analgesics are safer and more effective for pain relief, making this an incorrect for postoperative care.

Choice D reason: Avoiding deep breathing risks infection, a postoperative complication. Analgesics relieve pain, enabling deep breathing to promote lung expansion, making this incorrect and counterproductive.

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Correct Answer is A

Explanation

Choice A reason: Ibuprofen, an NSAID, increases the risk of gastrointestinal bleeding, especially in patients with a history of gastric ulcers. Holding the medication prevents exacerbation of the ulcer or perforation, prioritizing patient safety, making this the correct reason to withhold the drug.

Choice B reason: A bowel movement two days ago suggests mild constipation, not a contraindication for ibuprofen. While NSAIDs can cause gastrointestinal issues, constipation is not an immediate concern, making this choice incorrect for holding the medication.

Choice C reason: Joint pain rated 2/10 and intermittent may not warrant ibuprofen if pain is mild, but it is not a contraindication. The decision to hold is based on risks like ulcers, not pain severity, making this choice incorrect.

Choice D reason: Respiratory depression from opioids is unrelated to ibuprofen administration. While concerning, it does not contraindicate ibuprofen, which lacks respiratory effects, making this choice incorrect for holding the NSAID in this scenario.

A. Oranges B. Spinach C. Chicken breast D. White bread

Correct Answer is B

Explanation

Choice A reason: Oranges have minimal vitamin K, which does not significantly affect warfarin’s anticoagulant effect. They are safe for consumption, making this an incorrect food to avoid.

Choice B reason: Spinach is high in vitamin K, which counteracts warfarin by promoting clotting factor synthesis. Clients should limit such foods to maintain stable anticoagulation, making this the correct choice.

Choice C reason: Chicken breast is low in vitamin K and does not interfere with warfarin. It is a safe protein source, making it incorrect to include in foods to avoid.

Choice D reason: White bread contains negligible vitamin K, having no significant impact on warfarin efficacy. It is safe for consumption, making it incorrect for the teaching.

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A nurse is caring for a client who is postoperative following a cholecystectomy and reports incisional pain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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