A nurse is monitoring a client who is 36 hrs postoperative following gastric banding. Which of the following findings should the nurse expect?

The client is voiding at least 250 mL/hr.

The client is maintaining bed rest.

The client is tolerating clear liquids.

The client is consuming 1.000 calories daily.

Answer and Explanation

The Correct Answer is C

A. The client is voiding at least 250 mL/hr. This amount is excessive and not typical. The expected urine output for an adult is at least 30 mL/hr, so 250 mL/hr could indicate overhydration or diuretic use, which is not expected postoperatively.
B. The client is maintaining bed rest. Early ambulation is encouraged after surgery to prevent complications like deep vein thrombosis and promote recovery. Bed rest 36 hours post-op is not expected unless medically indicated.
C. The client is tolerating clear liquids. After gastric banding, clients typically start with clear liquids and gradually progress to more solid foods. Tolerating clear liquids at 36 hours post-op is an expected and positive finding.
D. The client is consuming 1,000 calories daily. At this stage post-op, calorie intake is significantly restricted, often much lower than 1,000 calories. Intake gradually increases as the diet progresses from liquids to solids.

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Correct Answer is C

Explanation

A. Apply a transparent dressing to the wound. Transparent dressings are not appropriate for active bleeding as they are too thin and do not absorb blood or provide compression to control hemorrhage.
B. Irrigate the wound with sterile water. Wound irrigation is not a priority when a client is actively bleeding. Controlling the bleeding takes precedence over cleaning the wound.
C. Apply direct pressure to the wound with thick dressing material. Direct pressure is the first-line intervention to control external bleeding. Applying firm pressure with a thick dressing helps compress the blood vessels and minimize blood loss.
D. Tie a tourniquet around the leg distal to the wound. A tourniquet should be applied proximal (above) the wound if needed and only after direct pressure fails to control the bleeding. Applying it distal is ineffective and potentially harmful.

A. "You can add honey to sweeten vegetables if they do not like them." B. "Raw carrots are a good snack to provide and can help with teething." C. "You can mash canned vegetables instead of purchasing baby food." D. "Introduce one new food every 3 to 5 days when starting solid foods"

Correct Answer is D

Explanation

A. "You can add honey to sweeten vegetables if they do not like them." Honey should be avoided in infants under 12 months due to the risk of infant botulism, a serious and potentially fatal illness caused by Clostridium botulinum spores.
B. "Raw carrots are a good snack to provide and can help with teething." Raw carrots pose a choking hazard for infants and should not be given in solid form. Teething rings or soft, age-appropriate snacks are safer alternatives for teething relief.
C. "You can mash canned vegetables instead of purchasing baby food." Canned vegetables often contain added sodium, which is not recommended for infants. Fresh or frozen vegetables without added salt are a safer option when preparing homemade baby food.
D. "Introduce one new food every 3 to 5 days when starting solid foods." This approach allows the caregiver to monitor for allergic reactions or food sensitivities. Introducing foods gradually helps identify the cause of any adverse response and promotes safe dietary progression.

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A nurse is monitoring a client who is 36 hrs postoperative following gastric banding. Which of the following findings should the nurse expect?

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