An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
Replace fluids intravenously based on intake and output.
Record the amount of daily wound drainage.
Assess skin condition and turgor for breakdown.
Turn every 2 hours around the clock from side-to-side.
The Correct Answer is A
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.
Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.
Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.
Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.
Correct Answer is B
Explanation
Choice A Reason: Beginning initial sterile wound care for surgical clients is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The PN may assist with wound care after the initial dressing change, but the RN is responsible for assessing the wound and initiating the plan of care.
Choice B Reason: Validating prescribed intravenous flow rates is a routine task that does not require clinical judgment and can be delegated to the PN. The PN has the knowledge and skill to check the IV orders, calculate the drip rate, and monitor the infusion.
Choice C Reason: Determining the need for urinary catheterizations is a nursing assessment that requires clinical judgment and cannot be delegated to the PN. The PN may perform urinary catheterizations as ordered by the physician, but the RN is responsible for evaluating the indication, risk, and benefit of the procedure.
Choice D Reason: Receiving a postoperative client and conducting the assessment is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The RN is responsible for receiving reports from the operating room, assessing the client's status, identifying potential complications, and initiating the plan of care.
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