After vertical banded gastroplasty, a 42-year-old male client returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a client-controlled analgesia (PCA) machine for pain control.
Which nursing action should be included in the postoperative plan of care?

Offer cups of fruit juices at frequent intervals.

Irrigate and reposition the NGT frequently.

Remind the client that PCA use may slow the return of bowel function.

Have the client splint the surgical site while deep breathing and coughing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Offering cups of fruit juices at frequent intervals is not recommended immediately postoperatively due to the risk of nausea and vomiting. The client should start with clear liquids and gradually progress.

Choice B rationale

Irrigating and repositioning the nasogastric tube frequently is not recommended as it can cause discomfort and dislodge the tube. Proper fixation and periodic checking are preferred.

Choice C rationale

Reminding the client that PCA use may slow the return of bowel function is not accurate. While opioids can slow bowel motility, PCA use is for pain management and should be monitored, not discouraged.

Choice D rationale

Having the client splint the surgical site while deep breathing and coughing helps prevent atelectasis and promotes lung expansion. It also reduces pain and protects the surgical incision during respiratory exercises. .

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Correct Answer is B

Explanation

Choice B rationale

After an open cholecystectomy, bowel sounds are typically absent or hypoactive due to the effects of anesthesia and the manipulation of the intestines during surgery. It takes time for normal bowel function to resume.

Choice A rationale

Normoactive bowel sounds are not expected immediately after abdominal surgery due to the temporary paralysis of intestinal motility caused by anesthesia and surgical manipulation.

Choice C rationale

Hyperactive bowel sounds are uncommon after surgery. They are more often associated with conditions like gastroenteritis or bowel obstruction rather than the immediate postoperative period of an open cholecystectomy.

Choice D rationale

Borborygmi, or loud, rumbling bowel sounds, are not expected after abdominal surgery. These sounds can indicate increased bowel activity, which is not typical in the immediate postoperative phase following an open cholecystectomy.

A. Explain that the medication may cause bruising. B. Ensure the client drinks at least 2000 mL of water daily. C. Administer the medication once a day before breakfast. D. Assess the client's stool for steatorrhea and mucus.

Correct Answer is B

Explanation

Choice A rationale

Sulfasalazine is more commonly associated with side effects such as gastrointestinal discomfort and hypersensitivity reactions, rather than causing bruising. Monitoring for bruising is not a specific intervention for this medication.

Choice B rationale

Ensuring the client drinks at least 2000 mL of water daily helps prevent crystal formation in the kidneys, a potential side effect of sulfasalazine. Adequate hydration also supports overall renal function and reduces the risk of kidney stones.

Choice C rationale

Sulfasalazine is usually taken multiple times a day with meals to reduce gastrointestinal side effects and improve absorption. Administering it once a day before breakfast is not the typical dosing schedule.

Choice D rationale

While it is important to monitor the client's stool, steatorrhea (fatty stools) and mucus are not specifically associated with sulfasalazine. The primary focus is on ensuring hydration and monitoring for other side effects such as rash and gastrointestinal discomfort.

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After vertical banded gastroplasty, a 42-year-old male client returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a client-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is 4 hours post-op after an open cholecystectomy. The nurse would expect the client's bowel sounds to be:

Correct Answer is B

Explanation

The client with irritable bowel disease (IBD) is prescribed sulfasalazine, a sulfonamide antibiotic. Which intervention should the nurse implement when administering the medication?

Correct Answer is B

Explanation

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After vertical banded gastroplasty, a 42-year-old male client returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a client-controlled analgesia (PCA) machine for pain control.
Which nursing action should be included in the postoperative plan of care?