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. 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?

A.

Bowel sounds, abdominal girth, and NG tube output

B.

Vital signs, cardiac rhythm, and peripheral pulses

C.

Blood Urea Nitrogen, Creatinine, and daily weight

D.

Respiratory rate, respiratory depth, and pulse oximetry

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. A soft, low sofa can make it difficult for the client to rise and sit safely after surgery, which may risk hip dislocation.

B. A dining room chair with armrests provides support for the client to help them sit down and stand up safely, making this the most appropriate choice.

C. A canvas lawn chair typically does not provide adequate support or height, which can complicate the sitting and standing process post-surgery.

D. A desk type, swivel chair may not be stable or supportive enough for the client, increasing the risk of falls or injury after the hip replacement.

Correct Answer is A

Explanation

A. Chewing food on the unaffected side helps to prevent triggering pain episodes in the affected side of the face, which is critical for managing trigeminal neuralgia effectively.

B. While maintaining oral hygiene is important, the timing of brushing teeth is less critical than managing pain during eating. Brushing teeth should be done gently to avoid pain but is not specifically prioritized over other interventions.

C. Avoiding an electric razor is not relevant to managing trigeminal neuralgia pain; it relates more to safety and comfort in shaving rather than pain management.

D. Food should not be served hot or cold as extreme temperatures can trigger pain in trigeminal neuralgia patients; it's better to serve food at a moderate temperature.

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