. The nurse is caring for a client in the immediate postoperative period following a pancreatoduodenectomy (Whipple) procedure. The nurse is assessing for decreased fluid volume in the client. What would the nurse assess first?
Bowel sounds, abdominal girth, and NG tube output
Vital signs, cardiac rhythm, and peripheral pulses
Blood Urea Nitrogen, Creatinine, and daily weight
Respiratory rate, respiratory depth, and pulse oximetry
The Correct Answer is B
A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratory function, these parameters are not the most direct indicators of fluid volume status.
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Correct Answer is C
Explanation
A. This statement indicates the client is aware of the importance of quitting smoking and is taking steps to do so, which is a positive action in managing their health after a lung cancer diagnosis.
B. Contacting the American Cancer Society shows the client and their family are seeking support, which is beneficial for coping with cancer, indicating good understanding of available resources.
C. Allowing others to smoke in the house poses significant health risks due to secondhand smoke exposure, which can aggravate the client's condition and hinder recovery. This indicates a lack of understanding regarding the dangers of smoking and the need for a smoke-free environment.
D. Spending quality time with family is a positive coping mechanism and reflects the client’s recognition of the importance of emotional support during their treatment journey.
Correct Answer is C
Explanation
A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.