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    Ati RN Fundamentals 2023 proctored exam

    A nurse is caring for a client who is 36 hr postoperative following an open cholecystectomy. Exhibits The nurse is planning care for the client. Complete the following sentence by using the lists of options. The nurse should prepare to insert dropdownand request a prescription fordropdown

    Explanation & Rationale

    Rationale for Correct Choices: A nasogastric tube: The client is experiencing nausea, vomiting, abdominal distention, and absence of bowel sounds, which are indicative of a possible postoperative ileus or bowel obstruction. Inserting an NG tube will help to decompress the stomach, prevent further buildup of gastric contents, and reduce the risk of aspiration. An antiemetic medication: The client is reporting nausea and vomiting, which can impede recovery and cause discomfort. Administering an antiemetic medication would help alleviate these symptoms, improve the client's comfort, and prevent complications like dehydration or electrolyte imbalances. Rationale for Incorrect Choices: An indwelling urinary catheter: There is no indication of urinary retention or output issues that would require an indwelling catheter. The client has an adequate urinary output (480 mL in 8 hours), the use of a catheter could increase the risk of urinary tract infections. An oral airway: An oral airway is not necessary since the client is alert and oriented, with no signs of airway obstruction. The client is able to breathe adequately, and there is no indication of respiratory distress requiring airway support. A bladder scan: The client is not experiencing urinary retention or issues with bladder function. The urinary output is adequate, so a bladder scan is unnecessary at this time. Arterial blood gases: There is no indication of respiratory distress or acid-base imbalances that would require arterial blood gas analysis. The client's vital signs, including oxygen saturation and respiratory rate, are stable, and no signs of metabolic issues are present.

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