Please answer each of the following prompts with a few

to the ep uncomfortable p chicken. The client is bent eating fried past incident nach and recalls a of similar dis nifort The client has a past cal history of hypertensi abdominal hysterectomy se amia. The c sent’s history includes an go and two hernia an epigastric hernia repair done three years ago, and an umbilical hernia repair done one year ago. Denies use of illicit substances. Phys al exam reveals an overweight client in severe pain with tenderness to palpation in the epigastric and right upper abdominal quadrants without rebound tenderness. Diagnostic tests reveal a thickened gallbladder and multiple stones blocking the biliary duct. A laparoscopic cholecystectomy is planned for the next day and the client is admitted to the same-day surgical holding unit. 1100: The client has a laparoscopic cholecystectomy and returns to the surgical same- day unit. The client’s VS are T 09.0″F (37 2.C). HR 110 BPM. RR 24 bpm, BP 150/92 mmHg. SpO, 03% RA, abdominal pain 9/10 on a 0 to 10 pain intensity scale that radiates to the right shoulder. No nausea or vomiting. Dressings dry and intact. The nurse reviews the client assessment date to prepare the plan of care. Complete the diagram by selecting from the choices below to specify which condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client’s progress. Nursing Actions Potential Com Select – Select Select – Select B C Notify the surgeon. Bleeding Pain characteristics Change abdominal Bile leak Hemoglobin, dressings. Adhesions hematocrit, Administer Trapped carbon platelets, red blood antinausea dioxide gas cells, bilirubin medication. Characteristics of Encourage deep vomitus breathing along with Respiratory status ambulation. and Spo Position on the left Drainage amount side with the right and type of dressings knee flexed. A. Potential Condition: Bile leak ++ Nursing Action #1: Notify the surgeon ++ Nursing Action #2: Change abdominal dressings. ++ Parameter to Monitor #1: O Drainage amount and type of dressings. ++ Parameter to Monitor #2: Pain characteristics B. Potential Condition: Bleeding ++ Nursing Action #1: Notify the surgeon ++ Nursing Action #2: Change abdominal dressings ++ Parameter to Monitor #1: O Hemoglobin, hematocrit, platelets, red blood cells, bilirubin ++ Parameter to Monitor #2: Drainage amount and type of dressings. C. Potential Condition: Trapped carbon dioxide gas ++ Nursing Action #1: Position on the left side with the right knee flexed ++ Nursing Action #2: Encourage deep O breathing along with ambulation ++ Parameter to Monitor #1: Respiratory Status and Sp02 ++ Parameter to Monitor #2: Pain characteristics D. Potential Condition: Adhesions ++ Nursing Action #1: Notify the surgeon ++ O Nursing Action #2: Administer antinausea medication ++ Parameter to Monitor # Pain characteristics ++ Parameter to Monitor #2: Characteristics of vomitus

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