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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fill out an incident report: While documentation is essential for quality improvement and accountability, it is not the immediate priority. The client’s safety must be addressed before any administrative action is taken.
B. Report the incident to the nurse manager: Notifying the manager is an important step in the reporting chain, but it should occur after ensuring the client is stable and receiving appropriate clinical care.
C. Notify the provider: The provider must be informed to assess for possible interventions or antidotes, but the nurse should first collect the client’s current clinical status to report meaningful information.
D. Measure the client's vital signs: Assessing the client’s condition is the first priority after a medication error. Vital signs provide critical information on the client’s immediate response and help guide the next steps in managing the error.
Correct Answer is A
Explanation
A. Prime the tubing with 0.9% sodium chloride: Normal saline is the only compatible solution used to prime blood transfusion tubing. It prevents clotting or hemolysis and ensures that blood components are not damaged during administration.
B. Attach a single-line administration set: A Y-type or dual-line administration set with a filter is required for safe transfusion. Single-line sets do not allow simultaneous saline flushing, which is necessary during transfusion to prevent clotting and maintain patency.
C. Use an IV catheter that is at least 24 gauge: While a 24-gauge catheter can be used in pediatric clients, adults require at least an 18–20 gauge catheter to prevent hemolysis and ensure rapid infusion of blood products when needed.
D. Use tubing that does not have a filter in the drip chamber: Blood administration sets must include a filter to trap clots and debris. Using tubing without a filter increases the risk of transfusion-related complications such as embolism or febrile reactions.
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