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 B
Explanation
A) "Decrease the ventilator flow rate.": Lowering the flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the client's respiratory distress. It is essential to identify and manage the cause first.
B) "Deliver breaths manually with a resuscitation bag.": This is the most appropriate immediate action. Manually providing breaths ensures the client receives adequate ventilation while the nurse assesses the situation. This intervention prioritizes the client's safety and oxygenation during respiratory distress.
C) "Assess for disconnected tubing.": While checking for disconnected tubing is an important step in troubleshooting the alarm, it may take time to assess and does not provide immediate support to the client in respiratory distress. Ensuring adequate ventilation is the priority.
D) "Reevaluate the client for an ET cuff leak.": Evaluating for an ET cuff leak is relevant but is not the most urgent action in this situation. The high-pressure alarm indicates an immediate problem that requires rapid intervention, such as manual ventilation, to stabilize the client.
Correct Answer is A
Explanation
A) "Practice pelvic-floor exercises regularly.": This instruction is essential for bladder retraining. Pelvic-floor exercises, such as Kegel exercises, strengthen the muscles that support the bladder and can help improve control over incontinence.
B) "Wear a pair of disposable briefs at bedtime.": While using disposable briefs can provide comfort and protection, this approach does not contribute to bladder retraining. It may inadvertently allow the client to rely on them instead of focusing on improving bladder control.
C) "Limit oral fluid intake to 1,000 milliliters per day.": Limiting fluid intake is generally not recommended, as it can lead to concentrated urine and potential bladder irritation. Adequate hydration is important for overall health and can help maintain normal bladder function.
D) "Drink 8 ounces of citrus juice per day.": Citrus juices can irritate the bladder in some individuals, leading to increased urgency and frequency. It’s usually advisable to avoid such irritants during bladder retraining, making this instruction less appropriate.
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