Nokea
A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
- A. Absence of nausea and vomiting.
- B. Passage of mucus from the rectum.
- C. Passage of flatus and feces from the colostomy.
- D. Absence of stomach drainage for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Passage of flatus and feces from the colostomy. This indicates that the gastrointestinal tract is functioning properly post-operatively. The nasogastric tube is typically removed once the client's bowel function has returned, as evidenced by the passage of flatus and feces from the colostomy. This indicates that the client's bowels are working and there is no longer a need for the tube to decompress the stomach. Choices A, B, and D are incorrect because the absence of nausea and vomiting, passage of mucus from the rectum, and absence of stomach drainage do not directly indicate the return of normal bowel function, which is the key factor for removing the nasogastric tube in this scenario.
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The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?
- A. Restricting pain medication
- B. Maintaining bedrest
- C. Avoiding coughing
- D. Irrigating the drain
Correct Answer: C
Rationale: The correct answer is C: Avoiding coughing. After umbilical hernia repair, coughing can increase intra-abdominal pressure and strain the surgical site, leading to potential complications like hernia recurrence or wound dehiscence. It is crucial to advise the client to avoid coughing to promote proper healing.
A: Restricting pain medication is not necessary as pain management is essential for the client's comfort and recovery.
B: Maintaining bedrest is not typically required after umbilical hernia repair, as early ambulation is often encouraged to prevent complications like blood clots.
D: Irrigating the drain is not typically part of the discharge teaching plan for umbilical hernia repair, as drains are usually removed before discharge.
The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to
- A. Eat a good supper when anorexia is not as severe.
- B. Eat less often, preferably only three large meals daily.
- C. Increase intake of fluids including juices.
- D. Select foods high in fat.
Correct Answer: C
Rationale: The correct answer is C: Increase intake of fluids including juices. This is because viral hepatitis can cause anorexia and a decreased taste for food, leading to poor nutrition. Increasing fluid intake, especially juices, can help provide essential nutrients and prevent dehydration.
A: Eating a good supper when anorexia is not as severe may not be effective in addressing the client's overall nutritional needs during the day.
B: Eating less often and only three large meals daily can worsen the client's nutritional status and may not address the decreased appetite and taste for food.
D: Selecting foods high in fat may not be appropriate for someone with viral hepatitis, as it can exacerbate liver inflammation and contribute to poor nutrition.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?
- A. Hiccups and diarrhea
- B. Fatigue and abdominal pain
- C. Constipation and fever
- D. Diaphoresis and diarrhea
Correct Answer: D
Rationale: The correct answer is D: Diaphoresis and diarrhea. Diaphoresis (excessive sweating) and diarrhea are classic signs of dumping syndrome, a common complication after gastrectomy. Diaphoresis occurs due to the rapid movement of food into the intestines, triggering the release of hormones leading to sweating. Diarrhea results from the rapid emptying of undigested food into the intestines. These symptoms typically occur within 30 minutes to 3 hours after eating in dumping syndrome.
Explanation for why the other choices are incorrect:
A: Hiccups and diarrhea - Hiccups are not typically associated with dumping syndrome.
B: Fatigue and abdominal pain - Fatigue and abdominal pain are not specific symptoms of dumping syndrome.
C: Constipation and fever - Constipation and fever are not typical signs of dumping syndrome.
In summary, diaphoresis and diarrhea are classic symptoms of dumping syndrome due to rapid emptying of food into the intestines, making
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?
- A. Lie down after meals to promote digestion.
- B. Avoid coffee and alcoholic beverages.
- C. Take antacids before meals.
- D. Limit fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: Avoid coffee and alcoholic beverages. This is because both coffee and alcohol can relax the lower esophageal sphincter, leading to increased risk of gastroesophageal reflux in clients with hiatal hernia.
A: Lying down after meals can actually worsen reflux symptoms by allowing stomach acid to flow back into the esophagus.
C: Taking antacids before meals may provide temporary relief but does not address the underlying cause of reflux.
D: Limiting fluids with meals can help reduce reflux by not distending the stomach, but it is not as crucial as avoiding coffee and alcohol.
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.