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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Correct Answer is D

Explanation

A. Carefully cleans and peels all fresh fruit and vegetables:
While cleaning and peeling fresh fruits and vegetables may contribute to food safety, it is not a specific indication of adherence to the DASH eating plan.

B. Uses only lactose-free dairy products:
The DASH eating plan encourages the consumption of low-fat or fat-free dairy products. Using lactose-free dairy products may be necessary for individuals with lactose intolerance, but it is not a specific behavior related to the DASH plan.

C. No longer includes grains in the daily diet:
The DASH eating plan includes whole grains as part of a balanced diet. Eliminating grains altogether is not consistent with the DASH plan, which encourages the consumption of whole grains.

D. Enjoys fat-free yogurt as an occasional snack food:
This is the correct answer. The DASH eating plan recommends the inclusion of low-fat or fat-free dairy products as part of a heart-healthy diet. Choosing fat-free yogurt as an occasional snack aligns with the principles of the DASH plan, which emphasizes low-fat dairy options.

A. Use standard precautions and wear a mask. B. Institute contact precautions for staff and visitors. C. Explain the purpose of a low bacteria diet D. Monitor the client's white blood cell count.

Correct Answer is ["B","D"]

Explanation

A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.

B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.

C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.

D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

Correct Answer is D

Explanation

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.)

Correct Answer is ["B","D"]

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?

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider of prior to the procedure?

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?