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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6.5"]
Explanation
Step 1 is: (75 units ÷ 150 mL) × 13 mL/hr = 6.5 units/hr.
Correct Answer is D
Explanation
Choice A rationale
Entering a copy of the patient's physician's orders for life-sustaining treatment in the electronic medical record is not a violation of privacy. It is standard practice to document such orders to ensure all healthcare providers are aware of the patient's wishes.
Choice B rationale
Giving change of shift report to the oncoming RN and CNA at the patient's bedside, with the patient's consent, is not a privacy violation. It ensures continuity of care and involves the patient in their care plan.
Choice C rationale
Explaining the meaning of an advanced directive to the patient is part of patient education and is not a violation of privacy. It is essential for patients to understand their options for future healthcare decisions.
Choice D rationale
Looking up the lab results for a neighbor's former spouse without a legitimate reason is a breach of privacy. Nurses must only access patient information that is necessary for their job role and responsibilities.
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