A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?
Maintain the client on an NPO status.
Determine if the client is over-hydrating to feel satiated.
Administer daily vitamin supplements.
Encourage positive self accolades for dietary adherence.
The Correct Answer is A
A. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.
B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.
C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.
D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.
B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.
C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.
D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.
Correct Answer is C
Explanation
A. Assess for signs of urine retention: While important, urinary retention is a later complication. It does not take priority over assessing for potentially serious effects like respiratory depression or excessive spread of anesthesia.
B. Inspect epidural catheter insertion site: Inspecting the site helps identify infection or dislodgement but is not the first priority. Neurological and respiratory assessments take precedence due to fentanyl’s CNS effects.
C. Monitor the client's dermatome level for sensation: This assesses the spread of the anesthetic, ensuring it hasn’t ascended to high thoracic levels, which could depress respiration. It’s the most urgent check for client safety.
D. Inquire if the client is experiencing breakthrough pain: Pain assessment is critical, but ensuring safe levels of sensory block must come first to rule out excessive anesthetic spread or complications.
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