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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Anticipatory grieving occurs when family members begin to experience grief before the actual loss, often in response to a terminal illness.
B. Situational refers to a sudden, unexpected loss or crisis, not the expected progression of a chronic illness.
C. Coping describes strategies used to deal with stress but is not a type of grief.
D. Hope is a positive outlook that may exist alongside grief but is not a form of grieving.
Correct Answer is D
Explanation
A. Providing brochures is informative but may not adequately support the client’s emotional adjustment to a new chronic illness.
B. Suggesting the client get affairs in order is premature and could increase anxiety rather than promote healthy coping.
C. Telling the client their family will be trained may be reassuring but does not directly address the client’s need to process feelings and cope with the diagnosis.
D. Encouraging the client to join a support group offers an opportunity to share experiences, gain emotional support, and learn coping strategies from others with similar conditions, which is the most therapeutic intervention to promote adaptation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.