After having a vertical sleeve gastrectomy performed, a 42-year-old male client returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a client-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the post-op plan of care for the first 24 hours?
Teach the client to support the surgical site while deep breathing and coughing
Teach that PCA use may slow the return of bowel function, so the client should not overuse it
Irrigate and reposition the NGT frequently
Offer cups of fruit juices at frequent intervals
The Correct Answer is A
A. Teach the client to support the surgical site while deep breathing and coughing: This action is appropriate as it helps prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. Supporting the surgical site while deep breathing and coughing helps reduce pain and discomfort during these activities.
B. This is an important teaching point for clients using PCA for pain control after surgery. Opioid medications used in PCA can lead to gastrointestinal motility issues, including constipation. However, pain management is central within the first 24 hours post operation.
C. Irrigating and repositioning the NGT frequently can increase the risk of complications such as displacement or irritation of the surgical site. NGT care should be performed as needed based on institutional protocols and the client's condition.
D. The client's diet will likely be advanced gradually, starting with clear fluids and progressing to full liquids and then solid foods as tolerated. Fruit juices may be introduced gradually as part of the liquid diet once the client's gastrointestinal function has recovered sufficiently.
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Related Questions
Correct Answer is D
Explanation
D. "You will probably begin to notice changes in how you feel with just a few weeks of diet and exercise.": This statement focuses on short-term benefits of weight loss, such as improvements in energy levels, mood, and overall well-being. Teenagers may be more motivated by immediate or short-term results rather than long-term outcomes. Feeling better quickly can provide positive reinforcement and encouragement to continue with healthy habits.
A. Water weight loss may not lead to significant changes in appearance or health outcomes, which are often key motivators for weight loss.
B. This statement emphasizes the importance of making lasting lifestyle changes for successful weight loss, which is a key concept for long-term success. However, it may sound daunting or overwhelming to a teenager.
C. Connecting weight loss to long-term health outcomes is unlikely to motivate some teenagers. This is because most teenagers feel immune to most chronic illnesses.
Correct Answer is B
Explanation
McBurney's point is located approximately one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus (navel), on the right side of the abdomen.
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