A client returned to the nursing unit after cholecystectomy with common bile duct exploration has bile leaking from around the wound. The most appropriate nursing intervention at this time would be to
a. assess the client further, asking about pain.
b. reassure the client that this is normal and reinforce the dressing.
c. monitor the client for elevations in blood pressure and pulse.
d. encourage the client to change position in bed.
A
The risk of bile leakage into the abdominal cavity is more specific for surgeries that involve the gallbladder. With hemorrhage and bile leakage, the client feels severe pain and tenderness in the right upper quadrant; the abdominal girth increases; bile or blood may leak from the wound; blood pressure drops; and tachycardia develops.
You might also like to view...
A nurse manager has required that all nursing staff attend an in-service on dealing with verbal threats. A staff nurse wonders why this is necessary since, "Words don't hurt me. I just ignore them
" What is the nurse manager's most appropriate response to this statement? 1. "Don't argue with me, I said everyone has to be in-serviced." 2. "Verbal threats often precede physical violence." 3. "I want my staff to be prepared to handle anything." 4. "This is a requirement from our accrediting agency."
An 8-year-old boy with a long history with cystic fibrosis has been admitted for malnutrition. The doctor has ordered labs for the child. The nurse clarifies which doctor's order before proceeding?
1. Obtain a stool sample for Clostridium difficile 2. Metabolic panel for hydration status 3. Serum albumin level to measure the nutritional status 4. Provide chest physiotherapy before bedtime
Which health belief system is commonly referred to as "third-world" beliefs and practices?
a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system
For infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.)
1. Food 2. Space 3. Water 4. Oxygen 5. Warmth 6. Darkness