An adult client who had bariatric surgery two months ago has developed a postoperative stricture. For the past week, the client has experienced nausea, vomiting, and anorexia, and is admitted to the hospital for fluid resuscitation. At this time the client denies feeling any pain. Which intervention should the nurse implement?

Keep the client NPO.

Administer daily vitamin supplements.

Provide protein-enriched shakes.

Encourage small frequent meals.

Answer and Explanation

The Correct Answer is A

Choice A reason: Keeping the client NPO (nothing by mouth) is essential to prevent further irritation of the gastrointestinal tract and to allow the postoperative stricture to heal. When the client is experiencing significant symptoms like nausea and vomiting, keeping them NPO can help manage these symptoms and prevent complications such as aspiration or worsening of the stricture.

Choice B reason: Administering daily vitamin supplements may be necessary for long-term nutritional management, especially after bariatric surgery. However, in the immediate setting of nausea, vomiting, and a postoperative stricture, this is not the priority intervention.

Choice C reason: Providing protein-enriched shakes may be beneficial for maintaining nutrition in the long term, but it is not appropriate when the client is experiencing nausea, vomiting, and anorexia. Oral intake should be limited until the symptoms subside and the stricture is addressed.

Choice D reason: Encouraging small frequent meals may be beneficial for managing long-term nutritional needs after bariatric surgery, but it is not appropriate during an acute episode of nausea, vomiting, and anorexia. The client should be kept NPO to prevent further complications and allow for proper healing.

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Correct Answer is B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

A. Clay coloured stool. B. Distended, hard, and rigid abdomen. C. Bile-stained emesis. D. Radiating, sharp pain in right shoulder.

Correct Answer is B

Explanation

Choice A reason: Clay-coloured stool is a symptom of bile duct obstruction. It indicates that bile is not reaching the intestines to help digest food. While this is important to note, it is not the most urgent finding that requires immediate reporting to the healthcare provider.

Choice B reason: A distended, hard, and rigid abdomen is a sign of possible peritonitis or other severe abdominal complications. This finding indicates a medical emergency that requires immediate attention and intervention by the healthcare provider. Prompt reporting is essential to prevent further complications and ensure appropriate treatment.

Choice C reason: Bile-stained emesis suggests that bile is being regurgitated, which is indicative of a blocked or compromised bile duct. However, this finding does not require as urgent reporting as a rigid abdomen, which could indicate a more serious condition.

Choice D reason: Radiating, sharp pain in the right shoulder is often referred pain from gallbladder issues. While this symptom is significant and should be monitored, it does not take precedence over the urgent finding of a distended and rigid abdomen that might indicate a severe complication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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