A nurse is monitoring a client who is 36 hrs postoperative following gastric banding. Which of the following findings should the nurse expect?
The client is voiding at least 250 mL/hr.
The client is maintaining bed rest.
The client is tolerating clear liquids.
The client is consuming 1.000 calories daily.
The Correct Answer is C
A. The client is voiding at least 250 mL/hr. This amount is excessive and not typical. The expected urine output for an adult is at least 30 mL/hr, so 250 mL/hr could indicate overhydration or diuretic use, which is not expected postoperatively.
B. The client is maintaining bed rest. Early ambulation is encouraged after surgery to prevent complications like deep vein thrombosis and promote recovery. Bed rest 36 hours post-op is not expected unless medically indicated.
C. The client is tolerating clear liquids. After gastric banding, clients typically start with clear liquids and gradually progress to more solid foods. Tolerating clear liquids at 36 hours post-op is an expected and positive finding.
D. The client is consuming 1,000 calories daily. At this stage post-op, calorie intake is significantly restricted, often much lower than 1,000 calories. Intake gradually increases as the diet progresses from liquids to solids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Rise slowly when getting out of bed." Furosemide can lead to significant fluid and electrolyte loss, causing orthostatic hypotension. Clients may experience dizziness or lightheadedness when changing positions. Rising slowly helps prevent falls and promotes safety.
B. “Taking furosemide can cause you to be overhydrated." Furosemide is a potent diuretic that promotes fluid excretion, not retention. The risk of dehydration and electrolyte imbalance is much higher than overhydration. Monitoring intake and output is essential.
C. "Eat foods that are high in sodium." High sodium intake increases fluid retention, which can worsen heart failure symptoms. Furosemide is often prescribed to manage fluid overload, and sodium-rich foods would counteract its effects. A low-sodium diet is recommended.
D. “Taking furosemide can cause your potassium levels to be high." Furosemide increases the excretion of potassium through the kidneys, often leading to hypokalemia. Low potassium levels can result in muscle weakness or cardiac arrhythmias.
Correct Answer is ["B","D"]
Explanation
A. Remove the thermometer from client's room for use on another client. Clients with C. difficile should have dedicated equipment (e.g., thermometers, stethoscopes) to prevent cross-contamination. Reusing equipment between patients increases the risk of infection transmission.
B. Wear a gown when providing care. Contact precautions are required for clients with C. difficile, including wearing a gown to protect against contamination from infectious material or surfaces.
C. Wear an N95 respirator when providing care. C. difficile is spread through the fecal-oral route, not airborne. A surgical mask is not required, and an N95 respirator is unnecessary unless another airborne condition is present.
D. Change gloves after contact with infectious material. Gloves must be changed after contact with contaminated materials to prevent spreading spores to other surfaces or clients. This is a standard part of contact precaution practices.
E. Wash hands with an alcohol-based cleaner. Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after caring for a client with this infection to properly remove the spores.
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