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) "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.

A. "You must be at least 21 years of age to become an organ donor."" B. "Your name cannot be removed once you are listed on the organ donor list." C. "Your desire to be an organ donor must be documented in writing." D. "I cannot be a witness for your consent to donate."

Correct Answer is C

Explanation

A) "You must be at least 21 years of age to become an organ donor.": This is inaccurate. Individuals as young as 18 can register as organ donors, provided they meet the necessary criteria.

B) "Your name cannot be removed once you are listed on the organ donor list.": This is misleading. Individuals can remove themselves from the organ donor list if they change their minds, as long as they follow the appropriate procedures.

C) "Your desire to be an organ donor must be documented in writing.": This is the correct answer. To ensure that a person's wishes regarding organ donation are respected, it is essential that they are documented, typically through a donor card or registry.

D) "I cannot be a witness for your consent to donate.": While it is true that a nurse may not serve as a witness for consent to donate, this response does not provide the client with useful information about organ donation itself.

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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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