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 D

Explanation

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

A. Place the bedside table at the foot of the bed. B. Assist the client to the toilet frequently C. Raise the side rails up when the client is in bed. D. Keep the television on during the night.

Correct Answer is B

Explanation

A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

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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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