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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.
Correct Answer is A
Explanation
A. Critical pathways should reduce health care costs. Critical pathways, also known as clinical pathways or care maps, are evidence-based, multidisciplinary plans that outline expected care and outcomes for specific conditions. They aim to improve care efficiency, reduce complications, and lower healthcare costs by standardizing care.
B. Nurses should discontinue the critical pathway if variances occur. Variances—deviations from the expected pathway—are documented and analyzed, not a reason to discontinue the pathway. They help identify areas for improvement or necessary adjustments in patient care.
C. Critical pathways have an unlimited timeframe for completion. Critical pathways are time-bound, with specific goals and milestones to be met within a set timeframe based on typical recovery patterns for the condition being treated.
D. Nurses' notes are used to create the critical pathway. Critical pathways are developed using evidence-based guidelines, expert consensus, and clinical research, not individual nurses’ progress notes. However, nurses do document progress and variances within the pathway.
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