Patient Data
The nurse reviews new data.
Which 5 nursing interventions are indicated for this client?
Apply sequential compression stockings when in bed.
Maintain strict bedrest for 12 hours after surgery.
Provide chilled beverages.
Change position frequently.
Encourage coughing and deep breathing.
Observe for signs and symptoms of dumping syndrome.
Keep client NPO
Maintain head at 45-degree angle.
Correct Answer : A,D,E,F,H
Choice A reason: Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT.
Choice B reason: Maintaining strict bedrest for 12 hours after surgery is not typically recommended as it can increase the risk of complications such as DVT and pulmonary embolism. Early mobilization is generally encouraged to promote circulation and respiratory function.
Choice C reason: Providing chilled beverages is not a specific nursing intervention indicated in the immediate postoperative period for bariatric surgery patients. Fluid intake should be carefully monitored and regulated, but the temperature of the beverages is not a primary concern.
Choice D reason: Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues.
Choice E reason: Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively.
Choice F reason: Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention.
Choice G reason: Keeping the client NPO (nothing by mouth) is a common immediate postoperative order, but as the patient progresses, they will be started on a liquid diet and advanced as tolerated. Therefore, it is not a nursing intervention that would be indicated indefinitely.
Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is: a, c, d.
Choice A: Avoid prolonged standing or sitting
Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.
Choice B: Cross legs at the knee but not at the ankle
Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.
Choice C: Continue wearing compression stockings
Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.
Choice D: Use a recliner for long periods of sitting
Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.
Choice E: Maintain the bed flat while sleeping
Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.
Correct Answer is ["2"]
Explanation
Step 1: We need to find out how many mL contain 10 mg of loratadine. Since 5 mg of loratadine is in 5 mL, we can set up a proportion to find out how many mL contain 10 mg.
So, 5 mg is to 5 mL as 10 mg is to X mL.
This gives us the equation: (5 mg ÷ 5 mL) = (10 mg ÷ X mL)
Step 2: Solving for X gives us X = (10 mg × 5 mL) ÷ 5 mg
Step 3: Simplifying gives us X = 10 mL
So, the client needs to take 10 mL of the loratadine suspension to get a dose of 10 mg.
Now, we need to convert this volume in mL to teaspoons, using the conversion factor you provided (1 teaspoon = 5 mL).
Step 4: We set up the conversion as follows: 10 mL × (1 tsp ÷ 5 mL)
Step 5: Simplifying gives us 2 tsp
So, the nurse should instruct the client to take 2 teaspoons of the loratadine suspension.
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