The nurse is caring for a client post-operatively following an open (incisional) cholecystectomy. Which would be the priority nursing intervention for this client?
Administer a narcotic analgesic every two hours.
Encourage a low-fat diet the first post-op day.
Encourage the use of the incentive spirometer.
Ambulate the client in the hall the first post-op evening.
The Correct Answer is C
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.
Correct Answer is B
Explanation
A. Picking up the implant with gloved hands does not ensure safety and proper handling of a radioactive material, as gloves do not provide adequate protection against radiation exposure.
B. Using long-handled forceps to pick up the implant and placing it in a lead container is the correct action, as it minimizes radiation exposure to the nurse and ensures the safe containment of the radioactive source.
C. Calling for the rapid response team is unnecessary in this scenario; the situation requires immediate containment of the radioactive material rather than emergency medical intervention.
D. Calling the radiation oncologist is not the first action; while it is important to inform the physician afterward, the priority is to secure the radioactive implant properly to prevent exposure.
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