A nurse is caring for a male client who is postoperative.
Which of the following client findings should the nurse identify as being consistent with dumping syndrome? Select all that apply.
Vital signs
Prescribed diet
Skin appearance
Blood glucose level
WBC count
Correct Answer : A,C,D
A. Vital signs. The client has a significantly elevated heart rate (110/min) and elevated blood pressure (178/82 mm Hg), both of which can be associated with autonomic responses in dumping syndrome. The dizziness and desire to lie down after eating are also classic symptoms. These signs reflect the body’s reaction to rapid gastric emptying and fluid shifts.
B. Prescribed diet. While a bland, soft diet is generally safe post-gastrectomy, it may not prevent dumping syndrome unless it includes specific modifications like low carbohydrate intake and small, frequent meals. However, this option alone does not directly indicate dumping syndrome.
C. Skin appearance. The client is noted to be diaphoretic and pale, which are common symptoms of dumping syndrome due to the vasomotor response and hypoglycemia that can follow rapid gastric emptying.
D. Blood glucose level. The client's fasting blood glucose dropped to 65 mg/dL, which is below the normal range. Hypoglycemia is a hallmark of late dumping syndrome, resulting from excessive insulin release after rapid carbohydrate absorption in the small intestine.
E. WBC count. The WBC count is within normal range (9,000/mm³) and does not indicate dumping syndrome or an infectious process. It is not relevant in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
- Prolonged rupture of membranes: Rupture of membranes lasting longer than 18 hours increases the risk of ascending bacterial infection, leading to conditions such as endometritis. This is a known risk factor for postpartum infection, especially following cesarean delivery.
- Polyhydramnios: An excessive amount of amniotic fluid overdistends the uterus, which can impair its ability to contract effectively postpartum, making uterine atony more likely. Atony can lead to increased bleeding or retained lochia.
- Prenatal anemia: While not directly causing infection, anemia impairs immune function, increasing a person's susceptibility to postpartum infections. It can also worsen recovery from infections or surgical wounds.
- High parity: Multiple prior pregnancies stretch the uterus over time, reducing myometrial tone, which predisposes to uterine atony. This makes it harder for the uterus to contract adequately after delivery, increasing the risk for hemorrhage or subinvolution.
Correct Answer is D
Explanation
A. Offer the client saltine crackers between meals. Saltine crackers are dry and salty, which can worsen symptoms of xerostomia (dry mouth) by further irritating and drying the oral mucosa. Moist, soft foods are more appropriate.
B. Suggest rinsing his mouth with an alcohol-based mouth wash. Alcohol-based mouthwashes should be avoided in clients with dry mouth as they can exacerbate oral dryness and irritation. Alcohol-free rinses are recommended instead.
C. Instruct the client on the use of esophageal speech. Esophageal speech is used in clients who have had laryngectomies, not those experiencing xerostomia. This intervention is unrelated to the client's current condition.
D. Provide humidification of the room air. Using a humidifier adds moisture to the environment, which helps relieve oral dryness and makes the client more comfortable, especially during sleep or in dry indoor climates.
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