An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?

Choice A rationale While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage. Choice B rationale An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous (IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure. Choice C rationale Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage. Choice D rationale Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.