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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important for patients with peripheral neuropathy to protect their feet, it’s recommended that they wear shoes at all times to prevent injury. Being barefoot, even inside the house, can increase the risk of foot injuries.
Choice B rationale
Regular foot exams are crucial for patients with peripheral neuropathy. Family members can assist with these exams, helping to identify any changes or injuries that may require medical attention.
Choice C rationale
Heating pads are not typically recommended for patients with peripheral neuropathy. Due to the loss of sensation in their feet, they may not realize if the pad is too hot, which could lead to burns.
Choice D rationale
Soaking feet in lukewarm water for extended periods is not typically recommended for patients with peripheral neuropathy. Prolonged exposure to water can dry out the skin and increase the risk of injury.
Correct Answer is A
Explanation
Choice A rationale
A lumbar puncture is a key diagnostic procedure for suspected bacterial meningitis. It allows for the collection of cerebrospinal fluid, which can be analyzed for signs of bacterial infection.
Choice B rationale
Skull radiography is not typically used to diagnose bacterial meningitis. While it can help identify abnormalities in the structure of the skull or brain, it cannot detect the presence of bacteria.
Choice C rationale
While an MRI can provide detailed images of the brain and surrounding tissues, it is not the primary tool for diagnosing bacterial meningitis. It may be used in conjunction with other tests, but a lumbar puncture is more definitive.
Choice D rationale
A CT scan can be used to detect abnormalities in the brain, such as swelling or inflammation, which could be indicative of meningitis. However, it cannot definitively diagnose bacterial meningitis.
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