Nokea
A client is 1 day postoperative after having Zanders diverticula removed. The client has a nasogastric (NG) tube in place. The NG tube is not being used for suctioning drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate?
- A. Document the findings as normal.
- B. Irrigate the NG tube with sterile saline.
- C. Notify the surgeon about this finding.
- D. Remove and reinsert the NG tube.
Correct Answer: C
Rationale: NG tubes placed during surgery should not be manipulated without surgeon orders. Lack of suction or drainage is not normal and requires notifying the surgeon for further evaluation, as irrigation or reinsertion could be harmful.
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The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which assessment. (Select all that apply.)
- A. Aphasia
- B. Dysphagia
- C. Eructation
- D. Halitosis
- E. Weight gain
Correct Answer: B,C,D
Rationale: Esophageal disorders commonly cause dysphagia (difficulty swallowing), eructation (belching), halitosis (bad breath), and weight loss. Aphasia is unrelated, as it involves speech difficulties typically from neurological issues.
A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first?
- A. Document the findings in the chart.
- B. Notify the surgeon immediately.
- C. Reassess the drainage in 1 hour.
- D. Take a full set of vital signs.
Correct Answer: D
Rationale: Bright red blood in the NG tube indicates possible bleeding, which requires immediate assessment. Taking vital signs first helps evaluate for shock, which is a priority before notifying the surgeon. Documentation and reassessment are secondary actions.
The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.)
- A. I just joined a gym, so I hope that helps me lose weight.
- B. I sure hate to give up my coffee, but I guess I have to.
- C. I will eat three small meals and three small snacks a day.
- D. Sitting upright and not lying down after meals will help
- E. Smoking a pipe is not a problem and I don't have to stop
Correct Answer: A,B,C,D
Rationale: Weight loss, avoiding caffeine (e.g., coffee), eating smaller frequent meals, and staying upright post-meals help manage GERD. All tobacco use, including pipe smoking, is a risk factor and should be avoided.
A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective?
- A. I can only take this medicine at night.
- B. I should take this on a full stomach.
- C. This drug decreases stomach acid.
- D. This should be taken 1 hour before meals.
Correct Answer: B
Rationale: Gaviscon should be taken with food in the stomach to form a protective barrier. It can be taken with meals at any time, and its mechanism of action is not to decrease stomach acid but to create a foam barrier to prevent reflux.
A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best?
- A. Arrange an intensive care unit tour.
- B. Assess the client's psychosocial status.
- C. Document the teaching and response.
- D. Have the client begin nutritional supplements.
Correct Answer: B
Rationale: Clients facing esophagogastrostomy are often anxious due to the procedure's complexity. Assessing psychosocial status is critical to address anxiety and provide tailored support, making it the best action compared to the more limited scope of the other options.