An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?

Monitor skin for breakdown.

Strict intravenous (IV) fluid replacement.

Encourage regular turning.

Assess wound drainage daily.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice B rationale
An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous
(IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure.
Choice C rationale
Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice D rationale
Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.

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Correct Answer is B

Explanation

Choice A rationale
Similar to, while spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
As in, drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
As in, clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
As in, avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.

A. Consume high-protein foods to reach an ideal body weight. B. Drink at least eight cups (1920 mL) of water each day. C. Use an electric heating pad when the pain is severe. D. Encourage active range of motion exercises to prevent stiffness.

Correct Answer is B

Explanation

Gouty arthritis is a form of inflammatory arthritis that occurs when uric acid crystals accumulate in the joints, causing severe pain and inflammation. Drinking plenty of water can help to flush the uric acid out of the body, reducing the risk of crystal formation and subsequent inflammation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?

Correct Answer is B

Explanation

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?

Correct Answer is B

Explanation

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client’s medical record should the nurse recognize as a contraindication for peritoneal dialysis?

The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?

A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?