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 B

Explanation

A. Warm skin temperature distal to pin site: Warmth in the extremity distal to the pin site is generally a positive sign and suggests adequate circulation.
B. A faint pedal pulse of the left leg suggests altered tissue perfusion distal to the traction site. This finding could indicate impaired blood flow to the foot, potentially due to the traction device compressing blood vessels or other circulatory issues.
C. Pain with movement of the left great toe: While pain with movement might indicate tissue injury, it's not necessarily indicative of altered tissue perfusion unless accompanied by other signs such as diminished pulse.
D. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered tissue perfusion.

A. A client who has sinus arrhythmia and is receiving cardiac monitoring. B. A client who has a hip fracture and a new onset of tachypnea. C. A client who has epidural analgesia and weakness in the lower extremities. D. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%).

Correct Answer is B

Explanation

A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

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

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