After a patient has undergone cholecystectomy, for which immediate complication would the nurse monitor?
Infection
Binding
Bowel obstruction
Dehydration
The Correct Answer is A
Choice A reason: Infection is a common immediate complication after any surgical procedure, including cholecystectomy. The nurse should monitor for signs of infection, such as fever, redness, swelling, or discharge at the surgical site, to ensure prompt intervention and treatment.
Choice B reason: The term "binding" is unclear and not typically used to describe a specific postoperative complication. This choice may be referring to issues such as adhesions or scar tissue, but these are not immediate concerns.
Choice C reason: Bowel obstruction can occur after abdominal surgery, but it is not the most immediate concern following cholecystectomy. It may develop later as a complication but is not the primary focus in the immediate postoperative period.
Choice D reason: Dehydration can be a concern if the patient is not taking in adequate fluids postoperatively, but it is not as immediate a concern as monitoring for infection.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: A question-and-answer session might provide information but does not specifically encourage the client to share their feelings and concerns about the colostomy. It's more about imparting knowledge rather than addressing emotional needs.
Choice B reason: Discussion is an effective strategy to encourage the client to share their feelings about the colostomy. It creates an open environment for expressing concerns, asking questions, and receiving emotional support.
Choice C reason: Role play can be useful in teaching new skills or preparing for specific situations, but it might not be the best initial approach for someone struggling to accept a new colostomy. Emotional readiness and comfort should be addressed first.
Choice D reason: Return demonstration is a method to confirm the client's understanding of a procedure by having them perform it. It is more appropriate for assessing practical skills rather than addressing emotional concerns and readiness to engage with the stoma.
Correct Answer is D
Explanation
Choice A reason: Securing the drain to the client's bed sheet is not appropriate as it does not ensure the drain is properly secured and could lead to accidental dislodgement.
Choice B reason: Measuring the drainage every hour for the first 8 hours is not standard practice. Usually, drainage measurement frequency is less frequent unless there are specific clinical concerns.
Choice C reason: Removing the JP drain should be done according to medical orders, and typically the nurse would not make the decision independently. The JP drain is usually removed when the output decreases to a minimal level and the surgeon orders its removal.
Choice D reason: Expelling the air from the JP bulb after emptying is the correct action to re-establish suction, which is necessary for the drain to function effectively.
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