Difficulty: Medium
Average Score: 78%
Simulated
An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101┬░ F (38.3┬░ C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg Which intervention is most important for the nurse to include in the client's plan of care?
Correct answer
D
Rationale
Signs of systemic infection and hypotension suggest possible sepsis from anastomosis leakage. IV fluid replacement is critical to stabilize hemodynamics and maintain perfusion.