A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Gastroccult positive emesis.
Strong foul smelling flatus.
Complaint of poor night vision.
Loose bowel movements.
The Correct Answer is A
Choice A reason: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
Choice B reason: Strong foul smelling flatus is a common side effect of BPD, which involves bypassing a large portion of the small intestine and creating a connection between the stomach and the colon. This results in malabsorption and bacterial overgrowth, which produce gas and odor.
Choice C reason: Complaint of poor night vision is a sign of vitamin A deficiency, which can occur after BPD due to reduced absorption of fat-soluble vitamins. The nurse should advise the client to take vitamin supplements and eat foods rich in vitamin A, such as carrots, sweet potatoes, and spinach.
Choice D reason: Loose bowel movements are another common side effect of BPD, which causes diarrhea and steatorrhea (fatty stools). The nurse should encourage the client to drink fluids with electrolytes and avoid foods that worsen diarrhea, such as greasy, spicy, or sugary foods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Potassium 4.7 mEq/L (4.70 mmol/L) is within the normal reference range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Potassium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high potassium level (hyperkalemia) can cause muscle weakness, irregular heartbeat, and cardiac arrest. A low potassium level (hypokalemia) can cause muscle cramps, fatigue, and arrhythmias.
Choice B reason: Magnesium 2.1 mEq/L (0.86 mmol/L) is within the normal reference range of 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Magnesium is an electrolyte that helps regulate the activity of enzymes, muscles, and nerves, as well as the balance of calcium and potassium in the body. A high magnesium level (hypermagnesemia) can cause nausea, vomiting, flushing, muscle weakness, and respiratory depression. A low magnesium level (hypomagnesemia) can cause muscle twitching, tremors, seizures, and cardiac arrhythmias.
Choice C reason: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range of 9 to 10.5 mg/dL (2.3 to 2.6 mmol/L). Calcium is an electrolyte that helps regulate the function of muscles, nerves, bones, and blood clotting. A high calcium level (hypercalcemia) can cause nausea, vomiting, constipation, confusion, kidney stones, and bone pain. A low calcium level (hypocalcemia) can cause muscle spasms, cramps, tingling, numbness, and stridor (a high-pitched sound when breathing). **This is a critical value that should be immediately reported to the healthcare provider**, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.
Choice D reason: Sodium 135 mEq/L (135 mmol/L) is slightly below the normal reference range of 136 to 145 mEq/L (136 to 145 mmol/L). Sodium is an electrolyte that helps regulate the balance of fluids and acids in the body, as well as the function of nerves and muscles. A high sodium level (hypernatremia) can cause thirst, dry mouth, confusion, seizures, and coma. A low sodium level (hyponatremia) can cause headache, nausea, vomiting, fatigue, muscle weakness, and confusion.
Correct Answer is D
Explanation
Choice A reason: Canned vegetables with additional table salt are not a good choice for someone with cholecystitis, because they are high in sodium, which can increase fluid retention and inflammation. However, this choice is not eliminated by the client, so it does not indicate successful teaching.
Choice B reason: Pasta with herbal butter and no meat sauce is a good choice for someone with cholecystitis, because it is low in fat and protein, which can trigger gallbladder contractions and pain. This choice is not eliminated by the client, so it does not indicate successful teaching.
Choice C reason: Citrus fruit and melon with a salt substitute are also good choices for someone with cholecystitis, because they are high in vitamin C and water, which can help dissolve gallstones and prevent infection. This choice is not eliminated by the client, so it does not indicate successful teaching.
Choice D reason: Whole milk and daily servings of ice cream are bad choices for someone with cholecystitis, because they are high in fat and cholesterol, which can worsen gallbladder inflammation and increase the risk of gallstone formation. This choice is eliminated by the client, so it indicates successful teaching.
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