A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?

Report of shoulder pain

Thick, green-brown drainage on dressing

Incisional pain 5 out of 10 on a pain scale

Abdominal dressing dry and intact

Answer and Explanation

The Correct Answer is B

This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.

Choice A, reporting of shoulder pain, is not the correct answer because this is a common finding post-cholecystectomy, which is often due to the presence of carbon dioxide used during the surgical procedure.

Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.

Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.

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Correct Answer is A

Explanation

The nurse should include monitoring for muscle paralysis in the plan of care for a client with botulism poisoning. Botulism is a serious bacterial illness that can cause muscle paralysis and can be life threatening. Monitoring for muscle paralysis is essential for early detection and intervention.

Choice B is incorrect because contact isolation is not necessary for the treatment of botulism.

Choice C is incorrect because increased salivation is not a common symptom of botulism.

Choice D is incorrect because clindamycin hydrochloride is not used to treat botulism.

A. Use a hair dryer to blow hot air into the cast to relieve itching. B. Perform neurovascular checks of the affected extremity every 2 hr. C. Position the fractured arm below the level of the client's heart. D. Immobilize the client's fingers using a hand splint.

Correct Answer is B

Explanation

The nurse should perform neurovascular checks of the affected extremity every 2 hours to monitor for any signs of compartment syndrome or impaired circulation. It is important to assess for the five Ps: pain, pulse, pallor, paresthesia, and paralysis. Using a hair dryer to relieve itching can cause burns and is not a recommended intervention. Positioning the fractured arm below the level of the client's heart can increase swelling and exacerbate pain. Immobilizing the client's fingers using a hand splint is not indicated unless there is a finger fracture or injury.

Choice A (Use a hair dryer to blow hot air into the cast to relieve itching) is not an answer because it can cause burns and is not a recommended intervention.

Choice C (Position the fractured arm below the level of the client's heart) is not an answer because it can increase swelling and exacerbate pain.

Choice D (Immobilize the client's fingers using a hand splint) is not an answer because it is not indicated unless there is a finger fracture or injury.

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A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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