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A nurse cares for a client who reports free air pain after a laparoscopic cholecystectomy. Which action should the nurse take?
- A. Assist the client with early ambulation.
- B. Apply a cold compress to the abdomen.
- C. Provide a warm beverage to relieve pain.
- D. Encourage coughing and deep breathing every hour.
Correct Answer: A
Rationale: The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.
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After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I should avoid fatty foods for a few weeks.
- B. Drinking at least 2 liters of water each day is suggested.
- C. I can resume normal activities immediately.
- D. I should expect severe pain for a few days.
Correct Answer: B
Rationale: Clients recovering from laparoscopic cholecystectomy should maintain adequate hydration to support recovery and prevent complications. Drinking at least 2 liters of water daily is a standard recommendation. Avoiding fatty foods is important but typically advised for longer than a few weeks. Immediate resumption of normal activities is not recommended, and severe pain is not expected.
A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.)
- A. Dispose of linens in a biohazard bag.
- B. Place the client in a private room.
- C. Wear a lead apron when providing client care.
- D. Bundle client care to minimize exposure.
- E. Initiate Transmission-Based Precautions.
Correct Answer: B,C,D
Rationale: The client should be placed in a private room, and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring the apron always faces the client. Bundling care minimizes exposure to radiation. Transmission-Based Precautions are not necessary for implanted radioactive iodine seeds.
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?
- A. Drainage from a fistula
- B. Pain in the incision site
- C. Nasogastric (NG) tube drainage
- D. Fever of 100.5°F (38.1°C)
Correct Answer: A
Rationale: Drainage from a fistula is a serious complication following a Whipple procedure, indicating potential leakage from surgical anastomoses, which requires urgent medical attention. Pain in the incision site and NG tube drainage are expected postoperative findings, and a mild fever may not be immediately concerning unless accompanied by other symptoms.
A nurse cares for a client who has obstructive jaundice. The client asks, 'Why is my skin so itchy?' How should the nurse respond?
- A. Bile salts accumulate in the skin and cause the itching.
- B. Toxes released from an inflamed gallbladder lead to itching.
- C. The nurse assesses the client who is itching.
- D. Itching is caused by a hypersensitivity reaction.
Correct Answer: A
Rationale: In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to the client? (Select all that apply.)
- A. Registered dietitian
- B. Nursing assistant
- C. Clinical pharmacist
- D. Certified herbalist
- E. Health care provider
Correct Answer: A,C,E
Rationale: Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to determine the best nutritional intervention. The nursing assistant and certified herbalist would not assist with this clinical decision.