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 C
Explanation
Choice A rationale:
Drowsiness is not a common side effect of phentermine/topiramate.
Choice B rationale:
An irregular menstrual cycle is not a common side effect of phentermine/topiramate.
Choice C rationale:
Phentermine/topiramate is a medication used to assist with weight loss. Topiramate, one of the components of this medication, can increase the risk of birth defects if taken during pregnancy. Therefore, it is important for women of childbearing age to avoid becoming pregnant while on this medication and to use effective contraception.
Choice D rationale:
Loose stools are a potential side effect of phentermine/topiramate, but this statement does not necessarily indicate an understanding of the medication's purpose and precautions.
Correct Answer is C
Explanation
Choice A rationale:
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
Choice B rationale:
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
Choice C rationale:
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
Choice D rationale:
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.
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