A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

The client is tolerating clear liquids.

The client is voiding at least 250 m L/hr.

The client is maintaining bed rest

The client is consuming 1000 calories daily.

Answer and Explanation

The Correct Answer is A

A. The client is tolerating clear liquids: Following gastric banding surgery, clients typically begin with clear liquids and gradually progress to more solid foods. Tolerating clear liquids 36 hours post-op is expected and indicates appropriate recovery.
B. The client is voiding at least 250 mL/hr: A urine output of 250 mL/hr is abnormally high and could suggest overhydration or other issues. Normal expected output is around 30–50 mL/hr postoperatively.
C. The client is maintaining bed rest: Prolonged bed rest increases the risk of complications like deep vein thrombosis. Clients are generally encouraged to ambulate early unless contraindicated.
D. The client is consuming 1000 calories daily: At 36 hours post-op, the client is not expected to consume high-calorie meals. Intake is usually limited to small amounts of clear liquids to prevent nausea and stress on the surgical site.

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Correct Answer is A

Explanation

Using proper body mechanics is vital to prevent injury and ensure safe lifting. Key principles include keeping the back straight and neutral to reduce spinal stress and bending at the knees and hips to engage stronger leg muscles rather than the lower back. Maintaining a shoulder-width stance provides stability, while holding objects close to the body decreases spinal strain. Lifting with the legs, not the back, further protects the spine. Twisting should be avoided—pivoting with the feet maintains alignment and reduces injury risk. Keeping the head and neck aligned with the spine improves posture and visual focus. Using smooth, controlled movements prevents muscle strain and dropped objects. Assessing an object’s weight before lifting helps determine if help or equipment is needed, preventing overexertion. Supportive footwear with a good grip ensures balance and minimizes fall risk. These ergonomic practices promote safety, reduce injuries, and are essential in both clinical and everyday environments.

A. Allow the client to walk unassisted near the nursing station. B. Establish an elimination schedule for the client. C. Raise the four bed rails on the clients bed. D. Silence the bed alarm when visitors are at the client's bedside.

Correct Answer is B

Explanation

A. Allow the client to walk unassisted near the nursing station: Even in a monitored area, allowing an at-risk client to ambulate unassisted increases the chance of falling. Clients on fall precautions should always have supervision or assistive devices during ambulation.
B. Establish an elimination schedule for the client: Scheduled toileting reduces the risk of unassisted attempts to get out of bed, a common cause of falls in hospitalized clients. It supports safety by addressing one of the most frequent fall triggers.
C. Raise the four bed rails on the client’s bed: Using all four bed rails can be considered a form of restraint and may increase fall risk if the client tries to climb over them. Two or three side rails are safer and still provide support.
D. Silence the bed alarm when visitors are at the client’s bedside: Bed alarms are a key fall prevention tool. Silencing them reduces their effectiveness and can delay the response to unsupervised movement, even if visitors are present.

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A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

Nursing Test Bank

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