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 mL/hr.

The client is maintaining bed rest.

The client is consuming 1.000 calories daily.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The client is tolerating clear liquids: After gastric banding, clients typically start with clear liquids within the first 24–48 hours. Tolerating clear liquids at 36 hours post-op is an expected and desired outcome that indicates gastrointestinal recovery and readiness to progress the diet gradually.

B. The client is voiding at least 250 mL/hr: This urine output is abnormally high and could indicate diuresis or overhydration. The expected minimum urine output is around 30 mL/hr, so this value exceeds normal expectations and is not typical postoperatively.

C. The client is maintaining bed rest: Early ambulation is encouraged after bariatric procedures to prevent complications such as deep vein thrombosis or pulmonary embolism. Prolonged bed rest is not expected or recommended.

D. The client is consuming 1,000 calories daily: At 36 hours post-op, clients are still on a very restricted intake—usually clear liquids or small sips—and would not be consuming 1,000 calories. This intake would be excessive and inappropriate at this stage of recovery.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

Rationale for correct choices:

Preeclampsia: The client presents with classic signs of preeclampsia, including elevated blood pressure (156/96 mm Hg), facial and dependent edema, hyperreflexia (DTR 3+), and right upper quadrant pain. Laboratory findings such as thrombocytopenia, elevated liver enzymes, and proteinuria also support this diagnosis.
Urinalysis: Proteinuria is a key diagnostic criterion for preeclampsia, and this client’s urinalysis reveals protein levels (25 mg/dL) above normal limits, indicating kidney involvement and supporting the preeclampsia diagnosis.
Pain assessment: Right upper quadrant pain is a significant symptom of preeclampsia, suggesting hepatic involvement such as liver capsule distension or possible HELLP syndrome. This pain, combined with other clinical and lab findings, signals severity and risk for maternal complications.

Rationale for incorrect choices:

Chorioamnionitis: This infection is typically accompanied by fever, uterine tenderness, and foul-smelling discharge. The client is afebrile with clear lungs and no uterine tenderness, making chorioamnionitis unlikely.
Preterm labor: No contractions or cervical changes were noted. The fetal heart rate is normal, and the client’s symptoms do not suggest imminent labor.
Serum WBC count: The client’s WBC count is within normal limits, which does not support infection or inflammatory processes related to chorioamnionitis.
Fundal assessment: Fundal height of 29 cm at 30 weeks is appropriate and shows no evidence of uterine enlargement or contraction indicative of preterm labor.
Fetal monitor results: The fetal heart rate is 140/min and stable, showing no signs of distress that would suggest preterm labor or infection.
Hemoglobin: Hemoglobin is within normal limits and does not contribute to the risk assessment for preeclampsia or infection.

A. Gelatin B. Shellfish C. Egg D. Milk

Correct Answer is C

Explanation

Rationale:

A. Gelatin: Gelatin allergies are more relevant when assessing for risk with certain vaccines like MMR or varicella, which may contain gelatin as a stabilizer. It is not a primary concern with most influenza vaccines.

B. Shellfish: Shellfish allergies are associated with reactions to iodine-based contrast, not vaccines. They do not impact the safety of receiving the influenza vaccine.

C. Egg: Many influenza vaccines are manufactured using egg-based processes, which can leave residual egg protein. Although most clients with egg allergies can now safely receive the vaccine, this allergy is still important to assess before administration.

D. Milk: Milk allergies are not linked to influenza vaccines and do not affect vaccine safety. There is no milk protein used in the manufacturing of flu vaccines.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown as evidenced by the client’s dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

A nurse is assessing a client prior to administering the influenza vaccine. The nurse should assess if the client has an allergy to which of the following foods?

Correct Answer is C

Explanation

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