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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A blood pressure reading of 150/92 mm Hg is indicative of hypertension, a symptom of preeclampsia, but it is not a therapeutic effect of magnesium sulfate.
B. A flushed face is not a therapeutic effect of magnesium sulfate and may indicate adverse effects such as magnesium toxicity.
C. A pulse rate of 100/min is within the normal range and is not a specific therapeutic effect of magnesium sulfate.
D. Negative clonus, assessed by dorsiflexing the client's foot and observing for absence of rhythmic oscillations or beats, indicates a therapeutic level of muscle relaxation provided by magnesium sulfate to prevent seizures in clients with preeclampsia
Correct Answer is B
Explanation
A. This response deflects the client's feelings and does not acknowledge the client's frustration.
B. This response acknowledges the client's feelings of frustration and validates their experience, showing empathy and understanding.
C. While it is important to encourage the client's progress, this response does not directly address the client's expressed emotions.
D. Suggesting that the client call their partner may not address the underlying feelings of frustration and may overlook the opportunity for therapeutic communication.
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