The nurse is assessing a client after bariatric surgery. The client complains of chest pain and shortness of breath. What is the priority nursing Intervention at this time?
Sit the client up and provide supplemental oxygen
Contact the physician and obtain an arterial blood gas
Explain that this is an expected finding after surgery
Encourage the use of the incentive spirometer
The Correct Answer is A
A. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Bowel sounds are typically present and indicate normal gastrointestinal motility. A change from normoactive (normal) to absent bowel sounds can indicate bowel obstruction, perforation, or peritonitis, which are serious complications of diverticulitis. This change warrants immediate reporting to the physician as it may indicate a worsening condition requiring urgent intervention.
A. A temperature of 101.2°F (38.4°C) is slightly elevated and may indicate the presence of infection, which is concerning in the context of diverticulitis. Fever is a common symptom of diverticulitis, but an elevated temperature may also suggest worsening infection or the development of complications such as abscess formation or perforation.
C. Left lower quadrant discomfort is a common symptom of diverticulitis due to inflammation in the sigmoid colon, where diverticula are most prevalent. While discomfort is expected in diverticulitis, the severity and persistence of pain should be assessed.
D. An elevated white blood cell (WBC) count is indicative of inflammation or infection and is commonly seen in diverticulitis. However, the significance of the elevation depends on the degree of increase and the presence of other clinical findings.
Correct Answer is C
Explanation
C. Protein is essential for tissue repair and maintenance, especially after surgery. Adequate protein intake can also help preserve muscle mass and promote satiety, which can be beneficial for weight management. However, it's important to choose lean protein sources and monitor portion sizes to avoid overconsumption.
A. After gastric banding (Lap-band) surgery, it is generally recommended to avoid high-fat foods. High-fat foods can contribute to weight gain and may increase the risk of complications such as dumping syndrome, which occurs when food moves too quickly from the stomach to the small intestine.
B. Adequate fiber intake is important for promoting bowel regularity and preventing constipation, which can be a concern after gastric banding surgery. However, it's essential to choose low-calorie, high-fiber foods to avoid overeating and to support weight loss goals.
D. After gastric banding surgery, it's generally recommended to avoid drinking fluids with meals. Consuming fluids during meals can cause the stomach pouch to fill too quickly, leading to discomfort and potentially stretching the pouch over time. It's typically advised to wait at least 30 minutes to 1 hour after meals before drinking fluids.
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