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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.

Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.

Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.

Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B rationale:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.

Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.

Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C rationale:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.

Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.

Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D rationale:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.

Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.

Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

A. Observe for edema around the ankles. B. Count the apical and radial pulses simultaneously. C. Measure the patient’s capillary glucose level. D. Auscultate the patient’s bowel sounds.

Correct Answer is D

Explanation

Rationale for Choice A:

Observing for edema around the ankles is a relevant assessment, but it's not the most crucial one in this context. Edema can be a sign of fluid retention, which is a potential side effect of hydromorphone. However, it's not the most immediate or dangerous concern associated with prolonged hydromorphone use.

Rationale for Choice B:

Counting the apical and radial pulses simultaneously is a technique used to assess for pulse deficits, which can indicate heart rhythm irregularities. While hydromorphone can potentially cause cardiac effects, it's not the most common or primary concern with its use. Other assessments take priority.

Rationale for Choice C:

Measuring the patient's capillary glucose level is important for patients with diabetes or those at risk for hyperglycemia. However, there's no direct link between hydromorphone use and blood glucose levels. This assessment isn't the most relevant in this specific scenario.

Rationale for Choice D:

Auscultating the patient's bowel sounds is the most important assessment for a patient who has been receiving hydromorphone for four days. Here's why:

Hydromorphone is a potent opioid analgesic that can significantly slow down gastrointestinal motility. This can lead to constipation, which, if severe, can progress to ileus (a complete lack of bowel movement).

Ileus is a serious complication that can cause abdominal pain, bloating, nausea, vomiting, and even bowel obstruction or perforation if left untreated.

Auscultating bowel sounds helps assess the patient's bowel activity and detect early signs of constipation or ileus. Normal bowel sounds are typically heard every 5-15 seconds. Decreased or absent bowel sounds can indicate decreased bowel activity.

Early identification of constipation or ileus allows for prompt intervention, such as increasing fluid and fiber intake, administering laxatives or stool softeners, and potentially discontinuing or adjusting the hydromorphone dosage. This can prevent the development of more serious complications.

Therefore, auscultating the patient's bowel sounds is the most important assessment for the nurse to complete in this case, as it directly addresses the most significant potential complication associated with prolonged hydromorphone use.

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Naxlex Comprehensive Predictor Exams

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound.Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Correct Answer is A

Explanation

The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is D

Explanation

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