. 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 B
Explanation
A. High-protein foods are not typically irritating after an esophagogastrectomy and are essential for healing and maintaining nutritional status. Clients should be encouraged to eat balanced meals with adequate protein.
B. Clients recovering from an esophagogastrectomy should avoid snacking between meals to prevent dumping syndrome, a common complication where food moves too quickly from the stomach to the small intestine. Instead, small, frequent meals should be consumed.
C. While pureed foods may be part of the immediate post-operative diet, the long-term goal is to gradually reintroduce solid foods, following the physician's dietary recommendations. A pureed diet is not necessarily required long-term.
D. Lying flat after meals increases the risk of reflux, which can be particularly harmful to clients recovering from esophageal surgery. Clients should be advised to stay upright after eating to aid digestion and prevent reflux.
Correct Answer is B
Explanation
A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.