An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg Which intervention is most important for the nurse to include in the client's plan of care?

Encourage regular turning.

Monitor skin for breakdown

Assess wound drainage daily.

Strict IV fluid replacement.

Answer and Explanation

The Correct Answer is D

A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.

B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.

C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.

D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Drink at least 8 cups (1920 mL) of water per day:
This is the correct answer. Adequate hydration is important in the management of gout because it helps to flush out uric acid and prevent the formation of urate crystals. Increasing fluid intake, especially water, is a key component of gout management.

B. Eat high protein foods to achieve ideal body weight:
While maintaining a healthy weight is important in managing gout, the emphasis should be on a balanced diet that includes adequate hydration and avoidance of foods high in purines, which can contribute to increased uric acid levels.

C. Encourage active range of motion to limit stiffness:
Active range of motion exercises can be beneficial for joint health, but the primary emphasis in gout management is on dietary and pharmacological interventions.

D. Use an electric heating pad when pain is at its worse:
Applying heat may provide some relief, but it is not the primary intervention for gout. Cold compresses or ice may be more appropriate for acute gout attacks.

A. Increasing anxiety B. Inappropriate laughter C. Weakened cough effort D. Asymmetrical weakness

Correct Answer is C

Explanation

A. Increasing anxiety:
While emotional and psychological aspects are important in holistic care, immediate intervention is usually required for physiological concerns. Increasing anxiety may need attention, but it is not as urgent as addressing potential respiratory issues.

B. Inappropriate laughter:
Changes in emotional expression, such as inappropriate laughter, can occur in ALS due to involvement of upper motor neurons. While notable, it may not be as urgent as addressing respiratory concerns.

C. Weakened cough effort.
In ALS, respiratory muscles can become affected as the disease progresses, leading to respiratory complications. Weakened cough effort is concerning because it can indicate potential respiratory muscle weakness, which may lead to difficulty clearing secretions and an increased risk of respiratory compromise or infection.

D. Asymmetrical weakness:
Asymmetrical weakness is a common feature of ALS, but it may not necessarily warrant immediate intervention unless there are sudden changes or signs of acute distress. Respiratory symptoms, such as weakened cough effort, often require more immediate attention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?