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 C
Explanation
Choice A rationale
Keeping the head of the bed elevated until the treatment is completed is not typically recommended to reduce the risk of vesicant extravasation during intravenous chemotherapy.
Choice B rationale
Instructing the client to drink plenty of fluids during the treatment does not directly reduce the risk of vesicant extravasation. Hydration can help maintain good vein health, but it does not prevent extravasation.
Choice C rationale
Monitoring the client’s intravenous site hourly during the treatment is a key action to reduce the risk of vesicant extravasation. Regular monitoring allows for early detection of any signs of extravasation, such as swelling or redness at the IV site.
Choice D rationale
Administering an antiemetic before starting the chemotherapy can help manage side effects such as nausea and vomiting, but it does not reduce the risk of vesicant extravasation.
Correct Answer is B
Explanation
Choice A rationale
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.
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