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.

Answer and Explanation

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

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Correct Answer is C

Explanation

A) Direct statements to the interpreter: The nurse should speak directly to the client rather than the interpreter. While the interpreter facilitates communication, maintaining direct eye contact and addressing the client fosters a more personal and respectful interaction.

B) Pause in the middle of sentences: Pausing mid-sentence can confuse both the interpreter and the client, potentially leading to misunderstandings. It’s better to complete thoughts and allow the interpreter to relay the information in full.

C) Speak in a normal voice at a natural pace: This action is appropriate as it ensures that the client can understand the information being communicated. Speaking normally allows the interpreter to accurately convey the message without distortion or misinterpretation, which is essential for effective communication.

D) Use gestures when speaking with the client: While gestures can help with communication, they should be used carefully, as they may not always translate effectively across cultures. Relying too much on gestures can lead to misunderstandings or misinterpretations of the intended message. It's best to use clear verbal communication first, supplemented by gestures only as needed.

A. "Take your temperature 1 hour after getting out of bed," B. "Take your temperature every night before going to bed." C. "Take your temperature immediately after waking and before getting out of bed." D. "Take your temperature within 30 minutes after your first morning void."

Correct Answer is C

Explanation

A) Taking your temperature 1 hour after getting out of bed is not appropriate for the basal body temperature method. For accurate tracking, temperature should be taken immediately upon waking, before any activity or movement that could affect the reading.

B) Taking your temperature every night before going to bed does not align with the basal body temperature method. This method requires consistent morning measurements to track ovulation accurately, as body temperature can fluctuate throughout the day.

C) Taking your temperature immediately after waking and before getting out of bed is the correct instruction. This ensures the reading reflects the body's resting temperature, which can help identify the slight increase that occurs after ovulation, aiding in family planning efforts.

D) Taking your temperature within 30 minutes after your first morning void is not suitable for this method. The ideal time is right upon waking, and any activity, including using the bathroom, can alter body temperature and lead to inaccurate readings.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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