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.

Answer and Explanation

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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Correct Answer is ["688"]

Explanation

Step 1:
Calculate the duration in minutes from 1400 to 1930. 1930 - 1400 = 5 hours 30 minutes = 330 minutes
Step 2:

Determine the infusion rate per hour. 125 mL/hour

Step 3:

Calculate the total volume infused. (125 mL/hour) × (330 minutes ÷ 60 minutes/hour) = (125 mL/hour) × (5.5 hours) = 687.5 mL Rounded to the nearest whole number = 688 mL.

A. Hemoglobin 12 mg/dL. B. Decreased serum Calcium. C. Pre-albumin in expected range. D. Cholesterol 140mg/dL. . .

Correct Answer is C

Explanation

Choice A rationale

Hemoglobin levels indicate general blood health but do not directly reflect nutritional status or TPN effectiveness.

Choice B rationale

Serum calcium levels reflect calcium metabolism, not overall nutritional status or the effectiveness of TPN.

Choice C rationale

Pre-albumin levels provide a sensitive indicator of nutritional status and protein synthesis, showing TPN effectiveness in improving nutrition.

Choice D rationale

Cholesterol levels can be influenced by various factors and do not specifically reflect the effectiveness of TPN in improving nutritional status. .

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The nurse is caring for a client following an open (incisional) cholecystectomy. Which would be the PRIORITY nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins a 1000 mL bag of DS 0.45 Saline plus 20 meq of KCl at 125 mL per hour at 1400. The IV is stopped due to signs of infiltration at 1930. How many milliliters will have infused during that time period? Round to the nearest whole number. Do not use trailing zeros.

Correct Answer is ["688"]

Explanation

A client is receiving Total Parenteral Nutrition (TPN) for severe malnutrition. Which laboratory result provides evidence supporting TPN effectiveness?

Correct Answer is C

Explanation

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