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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?

A.

Provide 60 mL (2 oz) of fluid intake every 5 min.

B.

Measure and compare abdominal girth daily.

C.

Provide a soft diet on the first postoperative day.

D.

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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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

Correct Answer is C

Explanation

A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.

B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.

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