The nurse is caring for a client following an open (incisional) cholecystectomy. Which would be the PRIORITY nursing intervention?
Monitor for the return of the client's gag reflex.
Have the client do deep breathing exercises.
Ambulate the client in the hallway.
Discuss dietary restrictions and menu choices.
The Correct Answer is B
Choice A rationale
Monitoring for the return of the client's gag reflex is important post-anesthesia, but it is not the priority intervention following an open cholecystectomy. The focus should be on respiratory function and preventing complications.
Choice B rationale
Deep breathing exercises are a priority nursing intervention following an open cholecystectomy to prevent pulmonary complications such as atelectasis and pneumonia. Ensuring proper lung expansion and oxygenation is crucial.
Choice C rationale
Ambulating the client is important for preventing complications such as deep vein thrombosis, but it is not the immediate priority. Early mobilization should be encouraged as soon as the patient is stable and can tolerate it.
Choice D rationale
Discussing dietary restrictions and menu choices is important for long-term recovery and prevention of further gallbladder issues, but it is not the immediate priority after surgery. Postoperative respiratory management takes precedence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Running for 15 minutes four times a week provides cardiovascular benefits but might not be enough duration or frequency for effective weight loss. While it helps in improving cardiovascular fitness, longer and more consistent activity is generally recommended for weight loss.
Choice B rationale
Walking for 30 minutes 5-7 days a week is an ideal cardiovascular exercise plan for weight loss. It is manageable, sustainable, and helps in burning calories effectively. Consistent, moderate-intensity exercise supports gradual and healthy weight loss.
Choice C rationale
Playing soccer for an hour every weekend provides cardiovascular benefits but is not frequent enough for sustained weight loss. Regular and more frequent exercise is necessary for effective and consistent weight loss results.
Choice D rationale
Lifting weights three times a week is excellent for building muscle and boosting metabolism but is not primarily a cardiovascular exercise. While important for overall fitness, combining it with aerobic activities like walking or running is essential for weight loss. .
Correct Answer is C
Explanation
Choice A rationale
Asking where the client buys food may provide some insight into access to healthy food options but does not directly assess the client's nutritional intake or risk of malnutrition.
Choice B rationale
Knowing if someone else prepares meals can impact the client's dietary choices but is not the most direct way to assess current nutritional status or risk of malnutrition.
Choice C rationale
Asking the client to describe what they eat in a typical day provides a clear picture of their daily nutritional intake and helps identify potential deficiencies or imbalances in their diet, making it the most direct assessment tool.
Choice D rationale
Assessing medication use that changes taste can be relevant but is secondary to understanding the client's overall dietary intake and habits. It can provide additional context but does not directly assess for malnutrition. .
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