A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?
Ambulate the client 48 hr after the procedure.
Provide a soft diet on the first postoperative day.
Provide 60 mL (2 oz) of fluid intake every 5 min.
Measure and compare abdominal girth daily.
The Correct Answer is D
A) Ambulate the client 48 hr after the procedure: Early ambulation is important to prevent complications such as deep vein thrombosis and promote recovery. However, ambulating the client 48 hours after the procedure may be too late. Early mobilization, usually within the first 24 hours, is encouraged.
B) Provide a soft diet on the first postoperative day: After gastric bypass surgery, the client typically starts with clear liquids and gradually progresses to a soft diet. Providing a soft diet on the first postoperative day is not appropriate and could cause complications.
C) Provide 60 mL (2 oz) of fluid intake every 5 min: Fluid intake should be carefully monitored and gradually increased. Providing 60 mL of fluid every 5 minutes is excessive and could lead to discomfort or complications such as dumping syndrome.
D) Measure and compare abdominal girth daily: Measuring and comparing abdominal girth daily helps monitor for signs of complications such as internal bleeding or anastomotic leaks. This intervention is crucial for early detection and prompt management of potential issues
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Ensure that all area rugs are rubber-backed:Rubber-backed rugs help prevent slips and falls by keeping the rugs securely in place on the floor. This is particularly important for someone recovering from knee surgery to avoid additional injury and ensure a safe home environment.
B) Wear slippers with cloth soles:Slippers with cloth soles can be slippery and increase the risk of falls. It is safer to wear slippers with non-slip soles to provide better traction and stability.
C) Place a towel on the floor outside of the shower:Placing a towel on the floor can create a slipping hazard. Instead, using a non-slip bath mat outside the shower is recommended to prevent falls.
D) Place a handrail in the entryway of the house:While placing a handrail in the entryway can be beneficial, it is not as immediately critical as ensuring that area rugs are rubber-backed to prevent falls throughout the home. Handrails are more commonly recommended for stairs and bathrooms.
Correct Answer is D
Explanation
A) "This type of seizure lasts 30 to 60 seconds.": While absence seizures typically last about 10 to 20 seconds, they can occasionally last longer, but they usually do not extend to 30 to 60 seconds. This statement may lead to misunderstanding of the duration.
B) "The child usually has an aura prior to onset.": Absence seizures generally do not have a warning or aura, which is more common in other types of seizures, such as focal seizures. Including this information could provide incorrect expectations.
C) "This type of seizure has a gradual onset.": Absence seizures have a sudden onset and are characterized by a brief loss of awareness rather than a gradual beginning. This statement does not accurately describe the nature of the seizures.
D) "This type of seizure can be mistaken for daydreaming.": This is correct. Absence seizures often result in a brief loss of consciousness that can be misinterpreted as the child simply daydreaming or zoning out, making this information essential for parents to understand.
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