Question

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

Answer 1

Correct Answers:

Apply compression stockings to the lower extremities

Rationale :

🔷 Post‑op abdominal surgery increases venous stasis, so graduated compression supports venous return and lowers DVT risk.

🔷 Stockings promote external calf pressure, enhancing venous velocity and reducing clot formation.

🔷 Client is 1 day postoperative and likely less mobile, making mechanical VTE prophylaxis essential.

🔷 Pillows under knees can cause venous pooling; stockings counteract pooling to maintain flow.

🔷 Early use of stockings pairs well with leg exercises/ambulation when tolerated for VTE prevention

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Answer 2

Correct Answers:

Place the head of the client's bed lower than the foot

Rationale :

🟣 Trendelenburg increases venous filling, making central vein cannulation easier.

🟣 The position reduces risk of air embolism by creating positive venous pressure at insertion.

🟣 Malnourished clients may have low intravascular volume; Trendelenburg offsets collapsing veins.

🟣 Asking to cough increases air embolism risk; Trendelenburg is the preferred maneuver.

🟣 Verification of line placement requires imaging, not just blood aspiration.

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Answer 3

Correct Answers:

100 mL of red drainage

Rationale :

♦ NG output should be green/yellow bile or small serosanguineous amounts early; red suggests active bleeding.

♦ 100 mL in 1 hr of frank red fluid is unexpected and warrants immediate provider notification.

♦ Post‑abdominal surgery, red NG drainage may indicate mucosal or anastomotic bleeding.

♦ Prompt recognition prevents hemodynamic instability and guides diagnostics/intervention.

♦ Document color/amount trends; this qualitative change is more critical than volume alone.

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Answer 4

Correct Answers:

Initiate cardiac monitoring for the client.

Rationale :

✅ Hypokalemia (K⁺ 2.8 mEq/L) predisposes to ventricular dysrhythmias; continuous telemetry is the first safety step.

✅ Monitoring allows detection of U waves, ST depression, and arrhythmias during correction.

✅ Before giving IV K⁺, ensure rhythm surveillance to respond to cardiac changes promptly.

✅ Vomiting/diarrhea cause total body K⁺ loss; the myocardium is highly sensitive to shifts.

✅ Cardiac monitoring also guides rate/route of potassium replacement safely.

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Answer 5

Correct Answers:

“should expect less than 25 ml of secretions per day in the drainage devices."

Rationale :

🔶 After modified radical mastectomy, drain removal criteria commonly include <25–30 mL/24 hr of serous output.

🔶 Tracking drain output reduces risk of seroma/hematoma and supports wound healing.

🔶 Flexing the arm or heavy lifting can impair lymphatic flow; monitoring output guides activity progression.

🔶 Stable, low output suggests adequate hemostasis and lymphatic control post‑op.

🔶 Education on daily measurement/recording improves follow‑up decisions and complication detection.

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Answer 6

Correct Answers:

" I should expect less than 25 mL of secretions per day in the drainage devices."

Rationale :

🔷 The <25–30 mL/24 hr threshold is a standard cue for drain removal readiness after breast surgery.

🔷 Consistently low serous output indicates reduced dead space and lower seroma risk.

🔷 Early heavy resistance/weights can raise output; education prevents strain on the operative site.

🔷 Accurate home monitoring of drainage supports timely provider decisions.

🔷 Knowing the target output empowers self‑management and reduces post‑op complications.

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Answer 7

Correct Answers:

Administer 0.9% sodium chloride

Rationale :

🟡 In DKA, initial priority is isotonic fluid resuscitation to restore circulating volume.

🟡 Dehydration and osmotic diuresis cause hypovolemia; fluids improve perfusion before insulin.

🟡 Starting insulin before fluids risks vascular collapse as glucose shifts intracellularly.

🟡 Early fluids also aid renal perfusion, facilitating K⁺ assessment/correction.

🟡 0.9% NaCl is the recommended first‑line crystalloid for DKA resuscitation.

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Answer 8

Correct Answers:

Administer 0.9% sodium chloride

Rationale :

🟢 Volume depletion is the most immediate threat; isotonic saline addresses hypotension/perfusion.

🟢 Fluids help correct hyperosmolality gradually, reducing cerebral edema risk.

🟢 Once perfusion improves, assess K⁺ and begin insulin infusion per protocol.

🟢 Bicarbonate is rarely indicated and reserved for severe acidosis with specific criteria.

🟢 Stepwise therapy prevents electrolyte shifts and supports safe glucose decline.

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Answer 9

Correct Answers:

Dark red granulation tissue

Rationale :

💎 Granulation tissue that is beefy red, moist, and bumpy signifies neovascularization and healing.

💎 Presence of granulation indicates effective perfusion and collagen matrix formation.

💎 Firm, indurated tissue suggests inflammation, not active healing.

💎 Dry brown eschar reflects necrosis and must often be debrided (site‑dependent).

💎 Yellow exudate may indicate slough or infection, delaying healing.

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Answer 10

Correct Answers:

Dark red granulation

Rationale :

🔶 Healthy granulation is red/pink and granular, signaling capillary growth and wound contraction.

🔶 It reflects controlled inflammation transitioning to proliferation.

🔶 Eschar denotes devitalized tissue; induration implies ongoing inflammation.

🔶 Pale/yellow drainage suggests bioburden or excess exudate, not optimal healing.

🔶 Document color, moisture, and texture to track progress and tailor dressing selection.

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QLexNursing

1 :
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

3 :
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

4 :
A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

5 :
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate a understanding of the teaching?

7 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

8 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

9 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

10 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

QLexNursing

1 : A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

2 : A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

3 : A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

4 : A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

5 : A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate a understanding of the teaching?

7 : A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

8 : A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

9 : A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

10 : A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

1 :
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

3 :
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

4 :
A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

5 :
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate a understanding of the teaching?

7 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

8 :
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

9 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

10 :
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?