A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?
Client report of back pain of 7 on a 0 to 10 scale
Excoriated folds of the client's panniculus
Hypoactive bowel sounds upon auscultation
urine output of 80 mL in the past hour
The Correct Answer is A
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
Choice B rationale:
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
Choice C rationale:
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
Choice D rationale:
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
Correct Answer is A
Explanation
Choice A rationale:
Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.
Choice B rationale:
Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.
Choice C rationale:
Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.
Choice D rationale:
Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.
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