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 B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
Correct Answer is B
Explanation
A. A client who has a fracture and is in balance suspension traction. This client is non-ambulatory and difficult to move quickly, so should not be evacuated first unless they are in immediate danger. They would require additional assistance and equipment to move safely.
B. A client who is ambulatory and receiving oxygen. This client is able to walk independently and can evacuate with minimal assistance, even while on oxygen. Evacuating ambulatory clients first helps clear the area quickly and frees up staff to assist less mobile clients.
C. A client who uses a wheelchair and is confused. While this client needs help due to confusion and mobility limitations, they are not the priority for first evacuation unless in immediate danger. They require more time and assistance.
D. A client who is bedridden and wears a hearing aid. This client is non-ambulatory and may have communication challenges, which makes evacuation more complex. They would be evacuated after ambulatory clients for safety and efficiency.
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