A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Loose bowel movements.

Occult positive emesis.

Strong foul smelling flatus.

Report of poor night vision.

Answer and Explanation

The Correct Answer is B

B. Occult positive emesis refers to vomiting that occurs without the client's awareness, meaning that the vomitus may not be easily visible or readily apparent. Vomiting can lead to significant fluid loss and dehydration, which is particularly concerning in a client who has undergone a biliopancreatic diversion procedure (BDP).
A. Loose bowel movements may indicate gastrointestinal disturbances or malabsorption issues commonly seen after biliopancreatic diversion procedure (BDP). BDP involves rerouting a significant portion of the small intestine, which can affect digestion and absorption of nutrients and fluids.
C. Strong foul-smelling flatus may indicate bacterial overgrowth or malabsorption issues in the gastrointestinal tract, which can occur after BDP. While foul-smelling flatus can be uncomfortable and indicative of gastrointestinal disturbances, it may not require immediate intervention.
D. Poor night vision may suggest vitamin deficiencies, particularly deficiencies in fat-soluble vitamins such as vitamin A, which can occur after BDP due to reduced absorption of nutrients. While poor night vision should be addressed to prevent long-term complications, it may not pose an immediate threat to the client's health.

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Correct Answer is D

Explanation

D. Assessing the time of symptom onset and determining if the symptoms have improved or worsened since onset is crucial for determining the urgency of the situation and guiding further management. This information helps the healthcare team identify the potential cause of the symptoms and decide on the appropriate course of action. Sudden onset of confusion and trouble speaking can be indicative of various serious conditions such as stroke, transient ischemic attack (TIA), intracranial hemorrhage, or other neurological emergencies.
A. Assessing for a swallowing reflex and performing communication deficit assessments are important aspects of the client's assessment but they may not be the immediate priority in the initial management of the client.
B. Administering aspirin to prevent further clot formation and platelet clumping may be appropriate if the client is suspected to have an ischemic stroke, but it should be done based on a comprehensive assessment
C. Initiating bilateral intermittent sequential pneumatic compression devices is indicated for preventing deep vein thrombosis (DVT) in hospitalized clients, but it is not the most immediate intervention for this particular client.

A. Continue with surgery as scheduled. B. Notify the surgical team to cancel the surgery. C. Perform a bedside pregnancy test. D. Calculate gestation from last menstrual cycle.

Correct Answer is C

Explanation

C. Performing a bedside pregnancy test is crucial before proceeding with surgery for a female of childbearing age who may be pregnant. This test provides immediate information about the client's pregnancy status and helps ensure that appropriate precautions are taken to safeguard the health of both the client and the potential fetus.
A. Proceeding with surgery without confirming the pregnancy status could potentially expose the fetus to unnecessary risks if the client is indeed pregnant.
B. Canceling the surgery without confirming the pregnancy status may also delay necessary treatment for the client's acute appendicitis.
D. may provide valuable information about the potential stage of pregnancy if the client is indeed pregnant. However, confirming the pregnancy status through a bedside pregnancy test is the most immediate and definitive action

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A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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