Patient Data
The nurse reviews new data.
Which 5 nursing interventions are indicated for this client?
Apply sequential compression stockings when in bed.
Maintain strict bedrest for 12 hours after surgery.
Provide chilled beverages.
Change position frequently.
Encourage coughing and deep breathing.
Observe for signs and symptoms of dumping syndrome.
Keep client NPO
Maintain head at 45-degree angle.
Correct Answer : A,D,E,F,H
Choice A reason: Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT.
Choice B reason: Maintaining strict bedrest for 12 hours after surgery is not typically recommended as it can increase the risk of complications such as DVT and pulmonary embolism. Early mobilization is generally encouraged to promote circulation and respiratory function.
Choice C reason: Providing chilled beverages is not a specific nursing intervention indicated in the immediate postoperative period for bariatric surgery patients. Fluid intake should be carefully monitored and regulated, but the temperature of the beverages is not a primary concern.
Choice D reason: Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues.
Choice E reason: Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively.
Choice F reason: Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention.
Choice G reason: Keeping the client NPO (nothing by mouth) is a common immediate postoperative order, but as the patient progresses, they will be started on a liquid diet and advanced as tolerated. Therefore, it is not a nursing intervention that would be indicated indefinitely.
Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Monitoring for changes in stool color can be important when taking certain medications, but it is not specifically required for itraconazole.
Choice B reason: Drinking grapefruit juice actually increases the effects of itraconazole by inhibiting its metabolism, not reducing its effects. Therefore, patients should avoid grapefruit juice while taking itraconazole.
Choice C reason: Antacids can decrease the absorption of itraconazole, making it less effective. Patients should take itraconazole with food and an acidic drink, like cola or orange juice, but not with antacids.
Choice D reason: Reporting any difficulty with breathing is appropriate advice for any medication and does not require additional instruction.
Correct Answer is A
Explanation
Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.
Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.
Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.
Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.
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