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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["125"]

Explanation

Step 1 is to convert the volume of the prescription from liters to milliliters. 1 liter is equal to 1000 mL. So, the prescription is for 1000 mL of lactated Ringer’s.

Step 2 is to divide the total volume by the total time. The prescription is to be infused over 8 hours. So, 1000 mL ÷ 8 hours = 125 mL/hr. Therefore, the nurse should program the infusion pump to deliver 125 mL/hr.

A. Lean beef, salads, and baked potatoes. B. Potatoes, low-fat breads, and applesauce. C. Oatmeal, raisins, and fruit with skin. D. Chicken, rice, and wheat products.

Correct Answer is C

Explanation

Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they do not specifically target the prevention of colon and rectal cancers. Red meat, in particular, has been associated with an increased risk of colorectal cancer.
Choice B rationale
Potatoes, low-fat breads, and applesauce can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Choice C rationale
A diet rich in oatmeal, raisins, and fruit with skin is high in fiber and antioxidants, which can help reduce the risk of colon and rectal cancers. This is especially important for clients with a strong family history of these cancers.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

Correct Answer is ["125"]

Explanation

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client’s discharge instructions?

A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?