. 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 ["A","B","D","E"]
Explanation
A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.
Correct Answer is C
Explanation
A. A history of Roux-en-Y gastric bypass surgery is not a direct risk factor for colorectal cancer; in some cases, it may reduce risk due to weight loss and dietary changes.
B. A high fiber, low fat diet is considered protective against colorectal cancer rather than a risk factor.
C. A personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, significantly increases the risk for developing colorectal cancer due to chronic inflammation and cellular changes in the colon.
D. Having a distant relative with colorectal cancer may increase risk, but the personal history of inflammatory bowel disease is a stronger risk factor warranting emphasis in teaching.