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 D

Explanation

A) Administer 0.9% sodium chloride IV: While fluid replacement is important in managing a thyroid storm, it is not the immediate priority compared to monitoring critical symptoms.

B) Provide a cooling blanket: Hyperthermia is a concern in a thyroid storm, and cooling measures are necessary, but they are secondary to addressing the cardiovascular effects.

C) Obtain the client's blood glucose: Monitoring blood glucose is important, especially in a hypermetabolic state, but it is not the most immediate concern in the context of a thyroid storm.

D) Monitor the client's cardiac rhythm: This is the priority action. Thyroid storm can cause significant cardiovascular complications, including tachycardia and arrhythmias. Continuous monitoring of the cardiac rhythm is essential to detect any life-threatening changes and to provide prompt intervention if necessary.

A. Document the client's condition every 15 min. B. Attach the restraint to the bed's side rails. C. Remove the client's restraint every 4 hr. D. Request a PRN restraint prescription for clients who are aggressive.

Correct Answer is A

Explanation

A) Document the client's condition every 15 min: This is an appropriate guideline for the use of restraints. Regular monitoring and documentation are essential to ensure the client's safety and well-being, and every 15 minutes is a commonly recommended interval.

B) Attach the restraint to the bed's side rails: Restraints should not be attached to the side rails, as this can pose a risk of injury if the rails are moved. Instead, they should be secured to a stationary part of the bed frame.

C) Remove the client's restraint every 4 hr: This guideline is not appropriate. Restraints should be removed at least every 2 hours to assess the client's needs and allow for movement, unless otherwise specified by a healthcare provider.

D) Request a PRN restraint prescription for clients who are aggressive: Restraints should not be used as a PRN intervention. They require a specific order based on an assessment of the client’s condition and should only be used when less restrictive measures have failed. Regular assessment and a clear plan of care are critical for the appropriate use of restraints.

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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?

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