Patient Data
Click to select the 5 most important nursing interventions for postoperative client care.
Encourage sitting up and ambulation
Monitor for bleeding once daily
Use Incentive spirometer every 1 hour
Promote adequate hydration
Assess for sedation after pain medications
Complete neurologic assessment every 2 hours
Administer pain medication after activity
Correct Answer : A,C,D,E,G
A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.
F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should be secure but not too tight to prevent injury or impaired circulation.
B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.
Correct Answer is D
Explanation
A. While chewing food well is important to aid digestion and prevent discomfort, meal timing and portion control are the primary concerns in gastric bypass patients.
B. Sipping fluids slowly is important, but fluids should generally be taken between meals rather than with meals to prevent stretching the stomach pouch and to avoid dumping syndrome.
C. Reducing fatty and gas-forming foods can help avoid discomfort, but this is less critical than ensuring proper food breakdown through thorough chewing.
D. After gastric bypass surgery, small, frequent meals help prevent dumping syndrome, a condition in which food moves too quickly from the stomach to the small intestine, causing nausea, dizziness, and diarrhea. Portion control is essential to avoid overstretching the reduced stomach pouch and ensure adequate nutrient absorption.
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