Nokea
The nurse is caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.
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Which of the following nursing actions should be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?
- A. Weekly weight of patient.
- B. Reposition the patient every 4 hours.
- C. Restrict sodium intake.
- D. Perform passive range-of-motion QID.
Correct Answer: C
Rationale: To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid retention. The patient should be weighed daily, not weekly. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity, patients should be repositioned at least every two hours. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.
Which of the following nursing actions is a priority when the nurse is caring for a patient with pancreatic cancer?
- A. Offer high-calorie, high-protein dietary choices.
- B. Offer psychological support for anxiety or depression.
- C. Educate about the need to avoid scratching pruritic areas.
- D. Administer prescribed opioids to relieve pain as needed.
Correct Answer: D
Rationale: Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.
Which of the following data obtained by the nurse during the assessment of a patient with cirrhosis is of most concern?
- A. The patient's hands flap back and forth when the arms are extended.
- B. The patient has ascites and a 2-kg weight gain from the previous day.
- C. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
- D. The patient complains of right upper-quadrant pain with abdominal palpation.
Correct Answer: A
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurological status.
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 50-year-old with persistent pancreatitis who has gnawing abdominal pain
- B. 48-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 38.8°C (101.8°F)
- D. 36-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
Correct Answer: C
Rationale: This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
The nurse is caring for a patient with cirrhosis who has 4+ pitting edema of the feet and legs. Which of the following assessments is priority for the nurse to monitor?
- A. Hemoglobin
- B. Temperature
- C. Activity level
- D. Albumin
Correct Answer: D
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.