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Patient Data

Exhibits

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.

Answer and Explanation

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

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Correct Answer is C

Explanation

Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.

Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.

Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.

Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.

A. Initiate bilateral intermittent sequential pneumatic compression devices. B. Place an indwelling urinary catheter and measure strict intake and output. C. Notify the stroke team to assist with acute assessment and management. D. Administer aspirin to prevent further clot formation and platelet clumping.

Correct Answer is C

Explanation

Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.

Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.

Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.

Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.

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Patient Data Exhibits The nurse reviews new data. Which 5 nursing interventions are indicated for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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Patient Data

Exhibits

The nurse reviews new data.

Which 5 nursing interventions are indicated for this client?