. 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. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.
Correct Answer is A
Explanation
A. The HPV vaccination is a form of primary prevention as it aims to prevent the initial occurrence of cervical cancer by protecting against the human papillomavirus, which is a major risk factor for this cancer.
B. BRCA1 and BRCA2 testing is a form of genetic testing used for risk assessment rather than prevention; it helps identify individuals at high risk for breast and ovarian cancers but does not prevent cancer itself.
C. Annual mammograms are a secondary prevention measure aimed at early detection of breast cancer rather than preventing the disease from occurring, as they help identify cancer in its early stages.
D. Rehabilitation exercises post-chemotherapy are supportive measures for patients undergoing treatment; they do not constitute primary prevention, which focuses on measures taken before cancer develops.