An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?
Monitor skin for breakdown.
Strict intravenous (IV) fluid replacement.
Encourage regular turning.
Assess wound drainage daily.
The Correct Answer is B
Choice A rationale
While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice B rationale
An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous
(IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure.
Choice C rationale
Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice D rationale
Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Similar to, while spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
As in, drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
As in, clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
As in, avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.
Correct Answer is C
Explanation
C. Prepare ice packs for placement in the patient’s axillary area.This response is crucial because the symptoms described—muscle rigidity and hyperthermia—are indicative ofmalignant hyperthermia, a serious reaction that can occur after the administration of succinylcholine, especially in conjunction with certain anesthetics. Immediate cooling measures, such as applying ice packs, are essential to help reduce the patient's elevated body temperature.
Rationale for Other Options:
- A. Call the PACU nurse to prepare for prolonged ventilatory support.: While preparing for ventilatory support may be necessary later, immediate action to address hyperthermia is critical.
- B. Hold a prescription for dantrolene until the fever is reduced.: Dantrolene is the antidote for malignant hyperthermia and should be administered as soon as possible rather than held.
- D. Determine if prescribed antibiotics were administered preoperatively.: This action is not relevant to the immediate management of malignant hyperthermia.
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