The nurse is caring for a patient who had surgery for gallbladder disease. Which of the following finding should the nurse immediately report to the physician?
A) Decreased breath sounds
B) Drainage of bile-colored fluid onto the abdominal dressing
C) Rigidity of the abdomen
D) Acute pain with movement
Chapter: 40
Feedback: The location of the subcostal incision will likely cause the patient to take shallow
breaths to prevent pain and this may result in decreased breath sounds. The nurse should remind patients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery, and analgesics should be administered for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, and this will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the physician, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.
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A. Avoid anticipatory guidance and focus on immediate problems. B. Praise the families often for what they are doing well. C. Refer them to social services agencies that work with immigrants. D. Teach them the laws and customs regarding discipline in the United States.
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