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 ["A","C","E"]

Explanation

A. Touch the client gently to announce presence: Gently touching the client’s arm or shoulder can help orient them to your presence and is a considerate way to communicate, especially when they have vision loss.

B. Ensure there is high-wattage lighting in the client's room: While good lighting is important, high-wattage lighting can create glare, which may be uncomfortable or disorienting for clients with vision loss. Instead, softer, diffused lighting is often more effective.

C. Keep objects in the client's room in the same place: Maintaining a consistent layout in the client’s environment helps them navigate safely and independently. It minimizes confusion and reduces the risk of accidents.

D. Approach the client from the side: Approaching from the front is typically better for clients with vision loss, as it allows them to see you (if they have some vision) and helps them feel less startled.

E. Allow extra time for the client to perform tasks: Providing extra time respects the client's pace and fosters independence. It acknowledges the challenges they may face due to vision loss, allowing them to complete tasks without feeling rushed.

A. "I try to respond to the baby quickly so she doesn't cry very long." B. "I want to meet other parents to see if they are going through the same t C. "I think the baby should be sleeping through the night by now." D. "I have several friends who come by to help out with the baby."

Correct Answer is C

Explanation

A. "I try to respond to the baby quickly so she doesn't cry very long.": This statement reflects a positive parenting behavior, indicating the parent is attentive and responsive to the baby's needs, which is protective against child abuse.

B. "I want to meet other parents to see if they are going through the same thing.": This shows a desire for social support and connection, which is a healthy response to the challenges of parenting.

C. "I think the baby should be sleeping through the night by now.": This statement can indicate unrealistic expectations about infant behavior. It may suggest frustration and a lack of understanding of normal infant sleep patterns, which can increase stress and risk for abusive behaviors if the parent feels overwhelmed.

D. "I have several friends who come by to help out with the baby.": This indicates a support system, which is protective and beneficial for a new parent, reducing the likelihood of stress and potential abuse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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