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 C
Explanation
A. Petroleum jelly is a petroleum-based product and can be a fire hazard when used with oxygen therapy. Water-based lubricants are recommended instead.
B. Alcohol is flammable, so it's better to avoid alcohol-based cleaners near oxygen therapy equipment.
C. Nail polish remover typically contains acetone, which is highly flammable. Since oxygen therapy increases the risk of fires, it is essential to avoid flammable substances around the client.
D. Synthetic fabrics can generate static electricity and should be avoided around oxygen. Cotton is preferable because it is less likely to produce static.
Correct Answer is B
Explanation
A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.
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