Nokea
A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
- A. Swelling of the abdomen
- B. Bloody diarrhea
- C. Vomiting blood
- D. An elevated temperature and arise in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Vomiting blood. When the esophageal balloon of the Sengstaken-Blakemore tube is deflated, the risk of esophageal variceal bleeding increases. Vomiting blood indicates active bleeding and requires immediate intervention. Swelling of the abdomen (A) is not directly related to deflating the balloon. Bloody diarrhea (B) is not a common complication of deflating the balloon. An elevated temperature and a rise in blood pressure (D) are not typical signs of complications related to the deflation of the esophageal balloon.
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Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?
- A. A cardiac monitor
- B. An intubation set
- C. A suction setup
- D. A tracheotomy set
Correct Answer: A
Rationale: The correct answer is A: A cardiac monitor. Vasopressin is a vasoconstrictor medication used to decrease blood flow to the bleeding esophageal varices. It can cause significant changes in blood pressure and heart rate, hence requiring close monitoring of the client's cardiac status. A cardiac monitor is essential to continuously monitor the client's heart rate and rhythm during vasopressin therapy.
B: An intubation set is not necessary for administering vasopressin to a client with bleeding esophageal varices.
C: A suction setup is not directly related to the administration of vasopressin for bleeding esophageal varices.
D: A tracheotomy set is not required for the administration of vasopressin for bleeding esophageal varices.
The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that
- A. This indicates inadequate preoperative bowel preparation.
- B. This is a normal, expected event.
- C. The client is experiencing early signs of ischemic bowel.
- D. The client should not have the nasogastric tube removed.
Correct Answer: B
Rationale: The correct answer is B: This is a normal, expected event. After colostomy creation, it is common for clients to pass malodorous flatus from the stoma as the intestines begin to function. This is due to the presence of normal intestinal flora. Choice A is incorrect as preoperative bowel preparation does not directly relate to malodorous flatus post-colostomy. Choice C is incorrect as ischemic bowel presents with more serious symptoms. Choice D is incorrect as nasogastric tube removal is not related to passing flatus from the stoma.
A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?
- A. Activity should be limited to prevent fatigue
- B. The diet should be low in calories
- C. Meals should be large to conserve energy
- D. Alcohol intake should be limited to 2 oz. per day.
Correct Answer: A
Rationale: The correct answer is A. For a client with viral hepatitis, limiting activity helps prevent fatigue and aids in recovery. Excessive activity can worsen symptoms. Choice B is incorrect because a low-calorie diet may not provide enough nutrients for the body to fight the infection. Choice C is incorrect as large meals can strain the liver and worsen symptoms. Choice D is incorrect as any alcohol intake can further damage the liver in viral hepatitis. In summary, choice A is correct as it promotes rest and aids recovery, while the other choices can potentially worsen the condition.
A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site.
A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period.
C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage.
D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:
- A. Diarrhea related to alteration in bowel elimination.
- B. Impaired skin integrity related to seepage.
- C. Impaired nutrition: More than body requirements related to high-fat diet.
- D. Impaired physical mobility related to surgical procedure.
Correct Answer: B
Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing.
A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions.
C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance.
D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance.
In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.