An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
Replace fluids intravenously based on intake and output.
Record the amount of daily wound drainage.
Assess skin condition and turgor for breakdown.
Turn every 2 hours around the clock from side-to-side.
The Correct Answer is A
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: The ability to update the equipment each year may be desirable, but not the most important question to consider. Updating the equipment may incur additional costs and may not be necessary or feasible depending on the type and function of the equipment.
Choice B Reason: The number of departments that can use the equipment is the most important question to
consider, as it reflects the potential impact and benefit of the equipment for the organization. The more departments that can use the equipment, the more efficient and cost-effective it will be.
Choice C Reason: The cost of equipment is an important question to consider, but not the most important one. The cost of equipment should be compared with the expected benefits and outcomes of using the equipment, not just in terms of monetary value, but also in terms of quality of care and patient satisfaction.
Choice D Reason: The need for annual repair is an important question to consider, but not the most important one. The need for annual repair may indicate the reliability and durability of the equipment, but it may also depend on the frequency and intensity of use, and the availability and accessibility of maintenance services.
Correct Answer is A
Explanation
Choice A Reason: This intervention is the most appropriate and effective for the nurse-manager to employ, as it provides clear and objective feedback to the staff nurse based on professional criteria, and encourages a positive and constructive approach to enhance the nurse's performance and development.
Choice B Reason: This intervention is not advisable, as it may create a false impression of the staff nurse's performance and fail to address the underlying issues or problems. Documenting the nurse's negative behaviors is important for accountability and improvement purposes, and avoiding it may expose the nurse manager to legal or ethical risks.
Choice C Reason: This intervention is not optimal, as it may demoralize or discourage the staff nurse and create a negative or hostile work environment. Focusing only on the areas of weakness may overlook the strengths and potential of the staff nurse, and may not foster a supportive and collaborative relationship between the nurse- manager and the staff nurse.
Choice D Reason: This intervention is not relevant, as it may divert the attention from the staff nurse's performance and shift the blame to external factors. Discussing how the inconsistency in the staff nurse's performance disrupts the routine of all of the staff members on the unit may not help the staff nurse identify and address their own areas of improvement, and may cause resentment or conflict among the team.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today