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?
Provide 60 mL (2 oz) of fluid intake every 5 min.
Measure and compare abdominal girth daily.
Provide a soft diet on the first postoperative day.
Ambulate the client 48 hr after the procedure.
The Correct Answer is B
A. Provide 60 mL (2 oz) of fluid intake every 5 min. Immediately post-surgery, fluid intake is usually more restricted and administered in smaller, more controlled quantities to prevent strain on the surgical site.
B. After gastric bypass surgery, monitoring for signs of complications such as leaks, obstructions, or internal bleeding is crucial. Measuring abdominal girth daily is not typically necessary unless specific complications are suspected.
C. Introducing a soft diet immediately post-surgery is typically delayed to allow healing; patients usually start with clear liquids.
D. Early ambulation is generally encouraged postoperatively to prevent complications like deep vein thrombosis and to promote gastrointestinal function, often starting as soon as the first postoperative day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.
Correct Answer is D
Explanation
A. This would involve irregular beats and potentially a visible compensatory pause, not a prolonged PR interval.
B. Atrial fibrillation features an irregularly irregular rhythm and no discernible PR intervals.
C. Defined by a heart rate less than 60/min with a normal rhythm and electrical pattern, which does not apply here given the normal rate and prolonged PR interval.
D. A first-degree atrioventricular (AV) block is characterized by a prolonged PR interval (greater than 0.20 seconds) in the presence of a normal heart rate and rhythm, which aligns with the client’s PR interval of 0.24 seconds and a heart rate of 69/min
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