An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg Which intervention is most important for the nurse to include in the client's plan of care?

Encourage regular turning.

Monitor skin for breakdown

Assess wound drainage daily.

Strict IV fluid replacement.

Answer and Explanation

The Correct Answer is D

A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.

B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.

C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.

D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

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Correct Answer is D

Explanation

A. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
Hyperaldosteronism is characterized by an excess of aldosterone, a hormone that regulates sodium and water balance. In cirrhosis, however, sodium retention is often related to other mechanisms such as portal hypertension and hypoalbuminemia, rather than hyperaldosteronism.

B. Decreased renin-angiotensin response related to an increase in renal blood flow.
Cirrhosis is more commonly associated with an activated renin-angiotensin-aldosterone system, leading to increased sodium and water retention. The increased renin-angiotensin response is a compensatory mechanism to maintain perfusion in the setting of cirrhosis and does not contribute to decreased renal blood flow.

C. Decreased portacaval pressure with greater collateral circulation.
This statement is not accurate. In cirrhosis, there is typically increased portacaval pressure due to portal hypertension, which can lead to the development of collateral circulation. However, this does not explain the edema and ascites seen in cirrhosis.

D. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
This is the correct choice. In cirrhosis, liver damage leads to decreased synthesis of albumin. Albumin plays a crucial role in maintaining colloidal oncotic pressure, and when it is decreased (hypoalbuminemia), fluid is more likely to leak out of blood vessels, resulting in edema. The same mechanism contributes to the development of ascites in the abdominal cavity.

A. Carefully cleans and peels all fresh fruit and vegetables B. Uses only lactose-free dairy products. C. No longer includes grains in daily diet. D. Enjoys fat-free yogurt as an occasional snack food

Correct Answer is D

Explanation

A. Carefully cleans and peels all fresh fruit and vegetables:
While cleaning and peeling fresh fruits and vegetables may contribute to food safety, it is not a specific indication of adherence to the DASH eating plan.

B. Uses only lactose-free dairy products:
The DASH eating plan encourages the consumption of low-fat or fat-free dairy products. Using lactose-free dairy products may be necessary for individuals with lactose intolerance, but it is not a specific behavior related to the DASH plan.

C. No longer includes grains in the daily diet:
The DASH eating plan includes whole grains as part of a balanced diet. Eliminating grains altogether is not consistent with the DASH plan, which encourages the consumption of whole grains.

D. Enjoys fat-free yogurt as an occasional snack food:
This is the correct answer. The DASH eating plan recommends the inclusion of low-fat or fat-free dairy products as part of a heart-healthy diet. Choosing fat-free yogurt as an occasional snack aligns with the principles of the DASH plan, which emphasizes low-fat dairy options.

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Naxlex Comprehensive Predictor Exams

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

Correct Answer is D

Explanation

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

Correct Answer is D

Explanation

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

The nurse has conducted a cancer prevention community education program. In evaluating the participants understanding of the carcinogens, which statement indicates an accurate understanding?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?