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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Position the client's knee slightly higher than the hips when up in a chair: This position can cause hip flexion greater than 90 degrees, increasing the risk of dislocation. Postoperative clients should keep their hips higher than their knees when sitting.
B. Raise the head of the client's bed to a high-Fowlers position: High-Fowlers positioning creates excessive hip flexion, which places strain on the new prosthesis and increases the likelihood of dislocation following hip replacement surgery.
C. Elevate the client's affected leg on a pillow when in bed: Elevating the leg can be appropriate for reducing swelling, but it does not prevent dislocation. Proper leg alignment is more critical than elevation in this context.
D. Keep an abduction pillow between the client's legs: An abduction pillow maintains the hip in proper alignment by preventing adduction and internal rotation, which are common causes of hip prosthesis dislocation in the early postoperative period.
Correct Answer is C
Explanation
A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.