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?

Choice A rationale
Heberden’s nodes are bony swellings that develop at the end joints (distal interphalangeal joints) of fingers, particularly the fingers closest to the nails. They are a characteristic feature of osteoarthritis, a degenerative joint disease. Osteoarthritis causes the protective cartilage in the joints to wear down over time, leading to the development of these bony growths, which can be painful and limit joint movement. Therefore, discussing strategies for managing chronic pain with the patient is the most appropriate action for the nurse to take.
Choice B rationale
While checking the patient’s radial pulses and capillary refill time is a part of a comprehensive physical assessment, it is not directly related to the management of Heberden’s nodes or osteoarthritis.
Choice C rationale
Although Heberden’s nodes are a sign of osteoarthritis, they are not typically an emergency that requires immediate notification of the healthcare provider. They are a common finding in individuals with osteoarthritis and are usually managed with conservative measures such as pain management and physical therapy.
Choice D rationale
Reviewing the patient’s dietary intake of high-protein foods is not directly related to the management of Heberden’s nodes or osteoarthritis. While a balanced diet is important for overall health, it does not specifically address the pain and limited joint movement associated with Heberden’s nodes.

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.