A nurse is caring for a client who is postoperative following a laparoscopic cholecystectomy. Which of the following actions should the nurse take?
Remove the abdominal dressings on the day of surgery.
Encourage ambulation on the day of surgery.
Place the client in a supine position postoperatively.
Offer the client ice cream postoperatively.
The Correct Answer is B
A. Dressings are typically not removed on the day of surgery to allow for observation of any bleeding or drainage. Dressing removal is usually performed by the surgical team or as directed by the healthcare provider.
B. Encourage ambulation on the day of surgery: Ambulation is important for preventing complications such as deep vein thrombosis and atelectasis, and to promote healing.
C. Postoperative positioning depends on the type of surgery performed and any specific patient needs, but placing the client in a supine position may not address comfort or respiratory considerations.
D. Offering ice cream, which is high in fat, may not be tolerated well immediately after this type of surgery.
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Related Questions
Correct Answer is B
Explanation
A. Dressings are typically not removed on the day of surgery to allow for observation of any bleeding or drainage. Dressing removal is usually performed by the surgical team or as directed by the healthcare provider.
B. Encourage ambulation on the day of surgery: Ambulation is important for preventing complications such as deep vein thrombosis and atelectasis, and to promote healing.
C. Postoperative positioning depends on the type of surgery performed and any specific patient needs, but placing the client in a supine position may not address comfort or respiratory considerations.
D. Offering ice cream, which is high in fat, may not be tolerated well immediately after this type of surgery.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should prioritize the client's immediate clinical needs based on the assessment data provided.
The first action should be to address the client's agitation, which is a sign of distress and can lead to safety issues. Therefore, the nurse should first address the client's "fall precautions" to ensure safety and prevent potential harm due to the client's disorientation and agitation.
Following this, the nurse should address the client's "urine collection" for urinalysis and culture and sensitivity (C&S), as it is critical to identify the cause of the client's febrile state and incontinence of foul-smelling urine, which could indicate an infection. This will allow for appropriate antibiotic therapy to be administered based on the sensitivity results.
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