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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer a topical analgesic:
Administering a topical analgesic can help alleviate pain and discomfort associated with oral thrush. However, it addresses the symptom rather than the cause of the issue.
B. Cleanse the mouth with swabs:
Cleansing the mouth with swabs can be part of the care plan for managing oral thrush. It helps remove debris and may reduce the fungal load in the mouth.
C. Obtain a soft diet for the client:
Providing a soft diet is important for clients with oral thrush as it minimizes irritation to the affected area. However, it may not be the first intervention; rather, it is part of the overall care plan.
D. Encourage frequent mouth care:
Encouraging the client to perform frequent mouth care is the most immediate and direct intervention. This includes gentle rinsing with a mild solution, which can help relieve symptoms and prevent the spread of the infection.
Correct Answer is D
Explanation
A. Guidelines for oxygen use:
While guidelines for oxygen use are important, addressing the root cause of the respiratory condition, which includes smoking cessation, is crucial for long-term management.
B. Methods for weight loss:
Obesity can contribute to respiratory issues, but in the immediate context of emphysema exacerbation and the need for oxygen therapy, smoking cessation is a more urgent concern.
C. Approaches to conserve energy:
Conserving energy is important for clients with emphysema, but addressing the impact of smoking on respiratory function is a more immediate priority.
D. Strategies for smoking cessation.
Smoking is a major contributor to the progression of emphysema and exacerbation of respiratory symptoms. Addressing smoking cessation is crucial in improving the client's respiratory function and overall health. Continuing to smoke can exacerbate emphysema and compromise the effectiveness of other interventions, including oxygen therapy.
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