The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy.
He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.
Obtain arterial blood gases (ABGs) prior to procedure.
Explain that the patient may be placed in five positions.
Perform the drainage immediately after meals.
Instruct the patient to breathe shallow and fast.
Correct Answer : B,C
Choice B rationale:
Gravity Facilitates Drainage:
Positioning the patient strategically utilizes gravity to encourage the flow of fluids and secretions away from the surgical site. This aids in preventing fluid accumulation and potential infection.
Reduces Pressure on Surgical Site:
Certain positions can minimize pressure on the incision and internal organs, promoting healing and reducing discomfort.
This is particularly important for patients with comorbidities like hypertension and heart failure, as they may have impaired wound healing and be more susceptible to respiratory complications.
Enhances Respiratory Function:
Specific positions can improve lung expansion and ventilation, which is essential for patients with a history of heart failure or respiratory issues.
This helps prevent atelectasis (collapsed lung areas) and pneumonia, which are common postoperative risks.
Common Post-Cholecystectomy Positions:
Semi-Fowler's Position:
The head of the bed is elevated 30-45 degrees, with knees slightly bent.
This position eases breathing, reduces pressure on the incision, and promotes drainage of fluids. Right Side-Lying Position:
The patient lies on their right side with a pillow between their knees.
This position encourages drainage from the liver and gallbladder, aiding in bile flow. Left Side-Lying Position:
The patient lies on their left side with a pillow between their knees.
This position promotes drainage from the stomach and pancreas, assisting in digestion. Supine Position:
The patient lies flat on their back with a pillow under their knees.
This position may be used for short periods, but prolonged supine positioning can increase pressure on the incision and lungs. High Fowler's Position:
The head of the bed is elevated 60-90 degrees, with knees slightly bent.
This position is often used for patients with respiratory issues or difficulty breathing, as it improves lung expansion.
Choice C rationale:
Performing drainage immediately after meals aids in efficient removal of bile and gastric secretions, preventing complications such as:
Bile Reflux:
Delayed drainage can cause bile to back up into the stomach, leading to nausea, vomiting, and discomfort. Infection:
Accumulation of fluids in the surgical site can increase the risk of bacterial growth and infection. Pancreatitis:
In rare cases, delayed drainage can cause inflammation of the pancreas due to obstruction of the pancreatic duct.
I'll address the rationales for choices A and D in the following sections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1: Identify the desired dose and the available concentration. Desired dose: 500 mg of vancomycin
Available concentration: 500 mg per 100 ml
Step 2: Determine the volume needed to deliver the desired dose.
Since the available concentration is 500 mg per 100 ml, no further calculation is required. The volume needed to deliver 500 mg of vancomycin is already 100 ml.
Step 3: Calculate the infusion rate in mL/hr.
The medication needs to be administered over 1 hour.
Therefore, the infusion pump should be set to deliver the 100 ml of solution over 1 hour. Infusion rate = 100 ml / 1 hour = 100 mL/hr.
Correct Answer is B
Explanation
Choice A rationale:
Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.
While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.
Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.
Therefore, total protein is not the most important laboratory value to review in this case.
Choice B rationale:
Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.
Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.
Choice C rationale:
Glucose is a type of sugar that the body uses for energy.
Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.
Therefore, glucose is not the most likely cause of the client's symptoms.
Choice D rationale:
Sodium is an electrolyte that helps regulate fluid balance in the body.
Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.
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