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 C

Explanation

Choice A rationale
Huff coughing is a method that forces mucus up your throat by breathing it in, holding it, and actively exhaling. It’s different from a typical cough and more effective in clearing mucus from the lungs. Pursed-lip breathing, which the patient is doing, is not part of the huff coughing technique.
Choice B rationale
Taking several shallow breaths before the next exhalation is not part of the huff coughing technique. The technique involves taking a slow and deep breath until your lungs are about 75% full, holding your breath for two to three seconds, and then exhaling slowly but strongly.
Choice C rationale
Instructing the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times is the correct method for huff coughing. This technique helps to move mucus from the smaller airways to the larger ones, making it easier to cough up and out.
Choice D rationale
Positioning the patient in the semi-Fowler’s position and applying oxygen is not part of the huff coughing technique. While oxygen therapy can be beneficial for patients with COPD, it does not directly aid in the huff coughing technique.

A. Chronic insomnia. B. Puffy, bleeding gums. C. Double vision. D. Blood pressure 100/78 mm Hg.

Correct Answer is C

Explanation

C. Double vision.Double vision, or diplopia, can indicatephenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen

.The other options do not require immediate intervention:

A. Chronic insomniais not a critical side effect of phenytoin and may be managed with lifestyle modifications or further assessment.
B. Puffy, bleeding gumsare common side effects associated with phenytoin (gingival hyperplasia) but are not immediately life-threatening.
D. Blood pressure 100/78 mm Hgis within normal limits and does not indicate a need for urgent action

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?

Correct Answer is C

Explanation

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

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?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

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.)

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?