A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?
The client is tolerating clear liquids.
The client is voiding at least 250 m L/hr.
The client is maintaining bed rest
The client is consuming 1000 calories daily.
The Correct Answer is A
A. The client is tolerating clear liquids: Following gastric banding surgery, clients typically begin with clear liquids and gradually progress to more solid foods. Tolerating clear liquids 36 hours post-op is expected and indicates appropriate recovery.
B. The client is voiding at least 250 mL/hr: A urine output of 250 mL/hr is abnormally high and could suggest overhydration or other issues. Normal expected output is around 30–50 mL/hr postoperatively.
C. The client is maintaining bed rest: Prolonged bed rest increases the risk of complications like deep vein thrombosis. Clients are generally encouraged to ambulate early unless contraindicated.
D. The client is consuming 1000 calories daily: At 36 hours post-op, the client is not expected to consume high-calorie meals. Intake is usually limited to small amounts of clear liquids to prevent nausea and stress on the surgical site.
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Related Questions
Correct Answer is C
Explanation
A. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy and is not relevant for managing xerostomia caused by radiation therapy to the mandible.
B. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia symptoms, so this is not appropriate.
C. Provide humidification of the room air: Increasing humidity helps keep the mucous membranes moist, relieving dry mouth symptoms and providing comfort for clients experiencing xerostomia after radiation therapy.
D. Offer the client saltine crackers between meals: Dry, salty foods like saltine crackers can exacerbate dry mouth and discomfort, so this recommendation is not appropriate for xerostomia management.
Correct Answer is B
Explanation
A. Remind the client to eat scheduled meals daily: At the end of life, appetite often decreases, and forcing scheduled meals can cause discomfort. Encouraging small, preferred foods as tolerated is more appropriate.
B. Offer the client a blanket to keep warm: Clients nearing end of life often experience cold intolerance due to decreased circulation and metabolism. Providing warmth helps maintain comfort and dignity.
C. Speak in a loud tone when addressing the client: Speaking loudly can be perceived as disrespectful or frightening, especially if the client is confused or hearing impaired. A calm, gentle tone is more supportive.
D. Place the client in a supine position: The supine position may increase discomfort or breathing difficulties in some terminal clients; positioning should focus on comfort and ease of breathing, often semi-Fowler’s or side-lying
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