The nurse is caring for a client who has just returned to the post-surgical unit following cholecystectomy for gallbladder disease. What assessment finding should the nurse immediately report to the health care provider?

The client has acute pain with movement

The client is not taking deep breaths

Bile-colored fluid in the Jackson Pratt drain.

Rigidity of the abdomen

Answer and Explanation

The Correct Answer is D

A. Pain is an expected finding after surgery, especially with movement. Pain should be managed, but it does not require immediate provider notification unless unrelieved or worsening significantly.

B. Shallow breathing is often due to pain after abdominal surgery. While this increases the risk of atelectasis or pneumonia, it is not the most urgent concern. The nurse should encourage deep breathing and incentive spirometry.

C. Bile-colored fluid in the drain may occur following gallbladder surgery and should be monitored. While excessive drainage or sudden increases may need to be reported, a small amount of bile-stained drainage is not unexpected.

D. Abdominal rigidity is a sign of peritonitis or intra-abdominal bleeding, both of which are life-threatening complications requiring immediate intervention. This assessment finding is a surgical emergency.

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Correct Answer is D

Explanation

A. A Monospot test is used to detect infectious mononucleosis, which is unrelated to chronic ear infections.

B. MRI is generally reserved for evaluating structural abnormalities, tumors, or complications, not routine chronic otitis media.

C. Lumbar puncture is used to diagnose central nervous system infections or conditions like meningitis, not ear infections.

D. Chronic otitis media can lead to hearing loss or speech delays. An audiology consult is appropriate to assess the child’s hearing and determine if further intervention, such as hearing aids or surgical options, is needed.

A. "I might cry uncontrollably and feel physically ill whenever I visit." B. "I might prepare for the loss by reducing the time I spend with my spouse." C. "I cannot believe that a merciful God would allow my leg to be amputated." D. "I may refuse to leave the bedside regardless of the reason."

Correct Answer is B

Explanation

A. Crying uncontrollably and physical illness reflect acute grief responses, not anticipatory grief.
B. Anticipatory grief occurs before an actual loss and may involve gradually detaching or preparing emotionally by reducing time spent with the loved one.
C. This reflects spiritual distress or anger rather than anticipatory grief.
D. Refusing to leave the bedside demonstrates denial or difficulty coping, not healthy anticipatory grieving.

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The nurse is caring for a client who has just returned to the post-surgical unit following cholecystectomy for gallbladder disease. What assessment finding should the nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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