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 ["C","D","E"]
Explanation
A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.
Correct Answer is B
Explanation
A. “Limit your fluid intake to 500 milliliters per day.”: Severely limiting fluid intake can lead to dehydration and concentrated urine, which may irritate the bladder and worsen symptoms. Adequate hydration is essential for urinary tract health and bladder training.
B. "Plan to urinate every 3 hours while you are awake.”: Scheduled voiding helps train the bladder to hold urine for longer periods and can reduce episodes of urgency and incontinence. A regular schedule is a foundational component of bladder retraining.
C. “Take your diuretic medication with your evening meal.”: Taking diuretics in the evening can lead to nocturia and sleep disruption. These medications should be taken in the morning to avoid increased nighttime urinary frequency.
D. "Decrease your intake of cranberry juice.": Cranberry juice is often encouraged for urinary health, particularly for preventing infections. It does not worsen urge incontinence and does not need to be restricted unless contraindicated for another reason.
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