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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect because reviewing the need for pneumococcal vaccine is not the most important intervention for the nurse to implement. Pneumococcal vaccine is recommended for people who are at high risk of pneumococcal infections, such as those with chronic diseases or immunosuppression. However, it is not a priority action for a client with neutropenia, which is a low number of neutrophils that increases the risk of bacterial and fungal infections.

Choice B reason: This is incorrect because implementing bleeding precautions is not the most important intervention for the nurse to implement. Bleeding precautions are indicated for clients who have thrombocytopenia, which is a low number of platelets that impairs blood clotting. However, this is not the case for a client with neutropenia, which affects the white blood cells that fight infections.

Choice C reason: This is incorrect because assessing vital signs every 4 hours is not the most important intervention for the nurse to implement. Vital signs are important indicators of the client's health status and may reveal signs of infection, such as fever, tachycardia, or hypotension. However, this is not a sufficient measure to prevent or treat infections in a client with neutropenia, who needs more aggressive and proactive interventions.

Choice D reason: This is correct because placing the client in protective isolation is the most important intervention for the nurse to implement. Protective isolation, also known as reverse isolation or neutropenic precautions, is a set of measures that aim to protect the client from exposure to pathogens that may cause infections. These include wearing gloves, masks, gowns, and eye protection; using sterile equipment and techniques; avoiding contact with people who are sick or have infections; and restricting visitors and fresh flowers or fruits.

A. Headache rated at 0 on 0 to 10 scale. B. Oxygen saturation level of 99%. C. Ambulates easily without vertigo. D. Blood pressure of 120/80 mm Hg.

Correct Answer is C

Explanation

Choice A: A headache rated at 0 on 0 to 10 scale is not a specific indicator of the effectiveness of an antihistamine. A headache may be caused by other factors, such as dehydration, stress, or sinus congestion.

Choice B: Oxygen saturation level of 99% is a normal finding and does not reflect the effect of an antihistamine. Oxygen saturation measures the amount of oxygen in the blood and can be affected by respiratory conditions, altitude, or smoking.

Choice C: Ambulating easily without vertigo is a sign that the antihistamine is effective. Vertigo is a common symptom of Ménière's disease, which is a disorder of the inner ear that causes episodes of spinning sensation, hearing loss, and tinnitus. Antihistamines can help reduce the fluid buildup in the inner ear and relieve vertigo.

Choice D: Blood pressure of 120/80 mm Hg is a normal finding and does not indicate the effect of an antihistamine. Blood pressure measures the force of blood against the walls of the arteries and can be influenced by factors such as heart rate, cardiac output, blood volume, and vascular resistance.

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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?

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Correct Answer is D

Explanation

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Correct Answer is C

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