Cognitive Skill: Generate Solutions Scenario: This morning the patient had an open cholecystectomy this morning for acut
Posted: Fri Jul 15, 2022 5:22 pm
Cognitive Skill: Generate Solutions
Scenario: This morning the patient had an opencholecystectomy this morning for acute cholecystitis and returnedto the nursing unit from the post anesthesia care unit (PACU) 4hours ago. She is now awake but drowsy. Using the pain intensityscale, she reports that the pain medication she received 1 hour agodecreased her pain level from an 8/10 to 4/10. She has a T tubedraining a moderate amount of bile. The dressing on her right upperquadrant is clean and dry. Vital signs are temperature98.9◦ (37.2◦ C), pulse 88 bpm, respirations16 per minute, BP 118/72 mmHg. She will be started on a clearliquid diet this evening.
NGN Item Type: Matrix
Use an X for the nursing actions listed below that areIndicated (appropriate or necessary), Contraindicated (could beharmful), or Nonessential (makes no difference or not necessary)for the patient’s care at this time. Only one selection can be madefor each nursing action.
Nursing Action
Indicated
Contraindicated
Nonessential
Administer analgesic before planned patient activity.
Clamp T tube to prevent loss of bile.
Assess patient’s serum glucose level daily.
Encourage the use of the incentive spirometer.
Maintain patient on bedrest in supine position.
Rationale for the above choices:
Cognitive Skill: Take Action
Scenario: The patient was discharged on the 5thpostoperative day 2 weeks ago. She is now at the surgery clinic forfollow-up care. Her T tube was discontinued before discharge andthere is now a small dressing over the insertion site, which isclean and dry. Her right upper quadrant surgical wound is clean anddry and open to air. Stitches are intact. She reports that she isfollowing the discharge instructions the nurse provided her beforeshe left the hospital. The patient has gained 5 pounds and shereports that she continues to eat fast food since it requires lesseffort than to prepare her own meals. She reports that she is noton a weight reduction program at this time. Although the patientreports that she does not have pain during her interview, shereports that she takes 2 Percocet tablets every 4 hours while sheis awake and that she will need the prescription to berefilled.
NGN Item Type: Highlighting/Enhanced HotSpot
Rationale for the above choices:
Cognitive Skill: Evaluate Outcomes
Scenario: This morning the patient had an opencholecystectomy this morning for acute cholecystitis and returnedto the nursing unit from the post anesthesia care unit (PACU) 4hours ago. She is now awake but drowsy. Using the pain intensityscale, she reports that the pain medication she received 1 hour agodecreased her pain level from an 8/10 to 4/10. She has a T tubedraining a moderate amount of bile. The dressing on her right upperquadrant is clean and dry. Vital signs are temperature98.9◦ (37.2◦ C), pulse 88 bpm, respirations16 per minute, BP 118/72 mmHg. She will be started on a clearliquid diet this evening.
NGN Item Type: Matrix
Use an X for the nursing actions listed below that areIndicated (appropriate or necessary), Contraindicated (could beharmful), or Nonessential (makes no difference or not necessary)for the patient’s care at this time. Only one selection can be madefor each nursing action.
Nursing Action
Indicated
Contraindicated
Nonessential
Administer analgesic before planned patient activity.
Clamp T tube to prevent loss of bile.
Assess patient’s serum glucose level daily.
Encourage the use of the incentive spirometer.
Maintain patient on bedrest in supine position.
Rationale for the above choices:
Cognitive Skill: Take Action
Scenario: The patient was discharged on the 5thpostoperative day 2 weeks ago. She is now at the surgery clinic forfollow-up care. Her T tube was discontinued before discharge andthere is now a small dressing over the insertion site, which isclean and dry. Her right upper quadrant surgical wound is clean anddry and open to air. Stitches are intact. She reports that she isfollowing the discharge instructions the nurse provided her beforeshe left the hospital. The patient has gained 5 pounds and shereports that she continues to eat fast food since it requires lesseffort than to prepare her own meals. She reports that she is noton a weight reduction program at this time. Although the patientreports that she does not have pain during her interview, shereports that she takes 2 Percocet tablets every 4 hours while sheis awake and that she will need the prescription to berefilled.
NGN Item Type: Highlighting/Enhanced HotSpot
Rationale for the above choices:
Cognitive Skill: Evaluate Outcomes