A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

Ambulate the client 48 hr after the procedure.

Provide a soft diet on the first postoperative day.

Provide 60 mL (2 oz) of fluid intake every 5 min.

Measure and compare abdominal girth daily.

Answer and Explanation

The Correct Answer is D

A) Ambulate the client 48 hr after the procedure: Early ambulation is important to prevent complications such as deep vein thrombosis and promote recovery. However, ambulating the client 48 hours after the procedure may be too late. Early mobilization, usually within the first 24 hours, is encouraged.

B) Provide a soft diet on the first postoperative day: After gastric bypass surgery, the client typically starts with clear liquids and gradually progresses to a soft diet. Providing a soft diet on the first postoperative day is not appropriate and could cause complications.

C) Provide 60 mL (2 oz) of fluid intake every 5 min: Fluid intake should be carefully monitored and gradually increased. Providing 60 mL of fluid every 5 minutes is excessive and could lead to discomfort or complications such as dumping syndrome.

D) Measure and compare abdominal girth daily: Measuring and comparing abdominal girth daily helps monitor for signs of complications such as internal bleeding or anastomotic leaks. This intervention is crucial for early detection and prompt management of potential issues

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Correct Answer is C

Explanation

A) Urinary frequency: This is a common and expected symptom during pregnancy, particularly in the first and third trimesters, due to hormonal changes and the growing uterus pressing on the bladder. It does not typically require reporting unless it is accompanied by pain or other concerning symptoms.

B) Faintness upon rising: While some women may experience dizziness or faintness due to hormonal changes or blood pressure fluctuations, it is not universally alarming unless it is frequent or severe. However, it’s important for the client to monitor this and report if it becomes problematic.

C) Swelling of the face: This is a concerning symptom that should be reported to the provider. Facial swelling can indicate possible preeclampsia, particularly when accompanied by high blood pressure or protein in the urine, and should be assessed promptly.

D) Bleeding gums: While some women may experience bleeding gums during pregnancy due to hormonal changes affecting the gums, it is generally not a significant concern unless it is severe or persistent. Regular dental care is advised, but it typically does not require immediate reporting to a healthcare provider.

A. A client who has a hip fracture and a new onset of tachypnea. B. A client who has sinus arrhythmia and is receiving cardiac monitoring. C. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%). D. A client who has epidural analgesia and weakness in the lower extremities.

Correct Answer is A

Explanation

A) A client with a hip fracture and new onset of tachypnea is a priority for assessment. Tachypnea can indicate respiratory distress, possible pulmonary embolism, or complications related to the fracture. Prompt evaluation is critical to ensure timely intervention and prevent further complications.

B) A client with sinus arrhythmia receiving cardiac monitoring is generally stable, as sinus arrhythmia is often benign and not immediately life-threatening. While ongoing monitoring is important, this client does not require immediate assessment over those presenting with more acute symptoms.

C) A client with diabetes mellitus and an HbA1c of 7.2% is slightly above the recommended target, but this finding does not indicate an immediate concern requiring urgent assessment. This client can be monitored but does not need priority attention compared to others with acute issues.

D) A client with epidural analgesia and weakness in the lower extremities is concerning, but if the client is stable and there are no additional alarming signs (such as respiratory distress or severe neurological changes), they can be assessed after more critical clients. Monitoring for side effects from epidural analgesia is important, but it is not as urgent as assessing new respiratory symptoms.

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A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

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