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 B

Explanation

Choice A rationale
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.

A. Advise the patient that the procedure is being performed correctly. B. Tell the patient to take several shallow breaths before the next exhalation. C. Instruct the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times. D. Position the patient in the semi-Fowler’s position and apply oxygen.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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

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 preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?

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?

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?

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

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?

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?

The parent of an adolescent tells the clinic nurse, “My child has athlete’s foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.”. Which instruction should the nurse provide?