A nurse at a provider's office is assisting in the care of a client who is 2 weeks postoperative
following a gastrectomy.
Exhibit 1
Medical History
Since discharge, the client reports several episodes of dizziness, "fast" heartbeat, and
abdominal cramping. Client states, "I am afraid to eat."
A nurse is reinforcing teaching with the client. Which of the following instructions should the
nurse include?
Select all that apply.
Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30
min before or after meals to decrease intestinal distension.
Eat several small meals per day is correct. The nurse should instruct the client to eat several
small, frequent meals instead of three large meals per day.
Consume high-protein snacks is correct. The client should eat snacks that are high in protein
and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in
dumping syndrome.
The nurse is reviewing the client's medical record.
Select the 3 findings that require nursing intervention.
ngn
Exhibit 1
Nurses' NotesDay 1 1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days. States, "I could barely breathe when I got up this morning, and I had a
throbbing headache." Client is alert and oriented to person, place, and time.Capillary refill is less
than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs. Pedal pulses are +2
bilaterally.Client reports a decreased appetite for the last 2 days.Day 3 0800:
,Supplemental oxygen administered at 2 L/min via nasal cannula. Client reports difficulty with
coughing up mucus. Encouraged client to cough and deep breathe.
Potassium level is correct. The nurse should identify that the client's potassium level is elevated,
which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing
intervention.
Temperature is correct. The nurse should identify that the client continues to have a fever as a
result of the body's immune system fighting the infection. Therefore, this finding requires nursing
intervention.
WBC count is correct. The nurse should identify that the client's WBC count remains elevated,
which indicates an infection. Therefore, this finding requires nursing intervention.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness
and full-thickness burns. Which of the following findings indicates that fluid resuscitation is
adequate?
Urine output is 50 mL/hr.
The nurse should closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is
adequate.
A nurse is assisting with the development of a plan of care to manage pain for a client who has
herpes zoster with lesions on the lower extremities. Which of the following interventions should
the nurse include in the plan of care?
Keep bed linens off of the affected areas.
The nurse should keep bed linens off of the affected areas by using a bed cradle, which will
relieve pain caused by the linens rubbing against the lesions.
A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip
arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?
Keep an abduction pillow between the client's legs.
, The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip
dislocation after surgery.
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A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has
Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
Offer a small snack at bedtime.
The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the
bedtime routine, which can help the client relax and prepare for sleep.
A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of the
teaching?
"I will notify my dentist about this procedure."
The nurse should remind the client to notify their dentist about the mechanical mitral valve
replacement before any procedures so antibiotic therapy can be initiated to reduce the risk for
endocardial infection.
A nurse is assisting with the care for a client who is 1 day postoperative following a hip
arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should
recognize that these findings indicate which of the following complications?
Pulmonary embolism
Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.
A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting.
Based on the client data, which of the following actions should the nurse take? (Click on the
exhibit tabs for additional information about the client. There are three tabs that contain
separate categories of data.)
Notify the charge nurse of the client's blood pressure.
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