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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
A diet high in protein and vitamins A and C can help promote wound healing. Protein is essential for tissue repair, and vitamins A and C play crucial roles in wound healing and immune function.
Choice B rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice C rationale
Maintaining as much bed rest as possible is not typically recommended for patients with venous leg ulcers. Physical activity and movement can help improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin can help detect early signs of worsening venous leg ulcers. Early detection and treatment can prevent complications and promote healing.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. Cold compresses can constrict blood vessels and reduce blood flow to the area, which may hinder the healing process.
Correct Answer is ["0.4"]
Explanation
Step 1 is to determine the amount of penicillin in each milliliter (mL) of the available solution. The vial is labeled as “Penicillin 500,000 units/mL”.
Step 2 is to divide the prescribed dose by the concentration per mL. So, the calculation is 200,000 units ÷ 500,000 units/mL. The result is 0.4 mL.
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