A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Gastroccult positive emesis.
Strong foul smelling flatus.
Complaint of poor night vision.
Loose bowel movements.
The Correct Answer is A
Choice A reason: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
Choice B reason: Strong foul smelling flatus is a common side effect of BPD, which involves bypassing a large portion of the small intestine and creating a connection between the stomach and the colon. This results in malabsorption and bacterial overgrowth, which produce gas and odor.
Choice C reason: Complaint of poor night vision is a sign of vitamin A deficiency, which can occur after BPD due to reduced absorption of fat-soluble vitamins. The nurse should advise the client to take vitamin supplements and eat foods rich in vitamin A, such as carrots, sweet potatoes, and spinach.
Choice D reason: Loose bowel movements are another common side effect of BPD, which causes diarrhea and steatorrhea (fatty stools). The nurse should encourage the client to drink fluids with electrolytes and avoid foods that worsen diarrhea, such as greasy, spicy, or sugary foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- The client is most likely experiencing compartment syndrome, which is a condition where increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can occur after a fracture, especially if a cast or splint is applied too tightly. Some of the signs and symptoms of compartment syndrome are severe pain, paresthesia, pallor, and pulselessness.
- Two actions the nurse should take to address compartment syndrome are:
- Elevate the extremity above the level of the heart to reduce swelling and improve venous return.
- Remove the cast or loosen the dressing to relieve the pressure and restore blood flow. This may require notifying the physician or obtaining an order for bivalving or cutting the cast.
- Two parameters the nurse should monitor to assess the client’s condition are:
- Capillary refill of the affected fingers, which should be less than 3 seconds. A prolonged capillary refill indicates poor perfusion and tissue ischemia.
- Blood pressure of the client, which should be maintained within normal limits. Hypotension can worsen the perfusion deficit and lead to tissue necrosis.
Correct Answer is ["100"]
Explanation
To answer this question, we need to find the rate of infusion in milliliters per hour (mL/hr) that will deliver 1 liter (1000 mL) of 0.9% sodium chloride, USP intravenously (IV) over 10 hours. We can use the following formula to calculate the rate:
Rate(mL/hr)=Volume(mL)/Time(hr)
Plugging in the given values, we get:
Rate(mL/hr)=1000mL/10hr
Simplifying, we get:
Rate= 100mL/hr
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