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?

Provide 60 mL (2 oz) of fluid intake every 5 min.

Measure and compare abdominal girth daily.

Provide a soft diet on the first postoperative day.

Ambulate the client 48 hr after the procedure.

Answer and Explanation

The Correct Answer is B

A.   Provide 60 mL (2 oz) of fluid intake every 5 min. Immediately post-surgery, fluid intake is usually more restricted and administered in smaller, more controlled quantities to prevent strain on the surgical site.
B.   After gastric bypass surgery, monitoring for signs of complications such as leaks, obstructions, or internal bleeding is crucial. Measuring abdominal girth daily is not typically necessary unless specific complications are suspected.
C.   Introducing a soft diet immediately post-surgery is typically delayed to allow healing; patients usually start with clear liquids.
D.   Early ambulation is generally encouraged postoperatively to prevent complications like deep vein thrombosis and to promote gastrointestinal function, often starting as soon as the first postoperative day.

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Correct Answer is C

Explanation

A. This type of play usually begins around ages 3 to 4.

B. While possible, this is more typical in slightly older children who engage in more complex forms of pretend play.
C. At 30 months (2.5 years old), children are typically engaged in simple pretend play and enjoy playing with larger, more manipulable toys like plastic trucks. Their motor skills and cognitive development at this stage support this type of play.
D. Coordination for jumping rope generally develops later, closer to school age.

A. difficulty sleeping B. frequent headaches C. BP 169/91 mm Hg D. Heart rate 78/min E. Respiratory rate 18/min

Correct Answer is ["A","B","C"]

Explanation

The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.

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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

A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C"]

Explanation

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