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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Related Questions
Correct Answer is D
Explanation
A. EMLA cream is used for pain relief and is not typically necessary for quick procedures like catheterization in toddlers.
B. This is not necessary for catheterization; it’s more relevant to a clean catch or midstream urine sample.
C. This size is too large for a toddler; smaller sizes, typically 5-8 French, are used for pediatric patients.
D. When performing a catheterization, especially in a sterile procedure like obtaining a urine culture, it is critical to wear sterile gloves to prevent infection
Correct Answer is C
Explanation
A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.
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