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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B. A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C. While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D. A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.

A. Sanguineous B. Purulent C. Serous D. Serosanguineous

Correct Answer is B

Explanation

A. Sanguineous drainage is typically bright red and composed mainly of red blood cells. It is common immediately after surgery but does not typically indicate infection.
B. Purulent drainage is thick, yellow, or greenish in color and contains pus, indicating infection. It requires prompt assessment and intervention.
C. Serous drainage is clear, watery, and pale yellow in color. It is typically a normal finding in surgical wounds.
D. Serosanguineous drainage is pink to pale red and contains a mixture of blood and serum. It is common in the early stages of wound healing.

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A nurse is caring for a client who is postoperative following a laparoscopic cholecystectomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are caring for this team of patients. Which patient is the priority to see first to collect data?

Correct Answer is B

Explanation

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Correct Answer is B

Explanation

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