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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Correct Answer is A

Explanation

Lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion. This reaction occurs when the client receives a blood type that is incompatible with their own. It can cause a rapid and severe response, including back pain, hypotension, fever, and chills. This should be reported immediately to the healthcare provider.

A. Explain the need to limit intake of oral fluids to reduce client discomfort. B. Teach the client techniques for performing intermittent catheterization. C. Remind the client to practice pelvic floor (Kegel) exercises regularly. D. Provide a bedside commode for immediate use in the client’s room.

Correct Answer is B

Explanation

Choice A rationale
Limiting intake of oral fluids is not typically recommended for a client with urinary retention related to sensorimotor deficits in multiple sclerosis. Adequate hydration is important for overall health and can help prevent urinary tract infections14.
Choice B rationale
Teaching the client techniques for performing intermittent catheterization is a common and effective strategy for managing urinary retention in multiple sclerosis. This can help the client maintain independence and improve quality of life14.
Choice C rationale
While pelvic floor (Kegel) exercises can help strengthen the muscles involved in urination, they may not be sufficient to manage urinary retention in a client with multiple sclerosis.
Intermittent catheterization (Choice B) is often more effective14.
Choice D rationale
Providing a bedside commode can be helpful for a client with mobility issues, but it does not directly address the issue of urinary retention in multiple sclerosis14.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is A

Explanation

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

Correct Answer is B

Explanation

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

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?

The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?

A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?