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A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
- A. To perform Valsalva's maneuver
- B. To take hold and hold a deep breath
- C. To exhale
- D. To inhale and exhale quickly
Correct Answer: B
Rationale: The correct answer is B: To take hold and hold a deep breath. This is because holding a deep breath helps prevent the aspiration of gastric contents when removing the nasogastric tube. By taking a deep breath and holding it, the client creates positive pressure in the lungs, which can help prevent the contents from entering the airway.
Rationale for other choices:
A: Performing Valsalva's maneuver (straining while holding breath) can increase intra-abdominal pressure and potentially push gastric contents upward, increasing the risk of aspiration.
C: Exhaling does not provide the same protection against aspiration as holding a deep breath.
D: Inhaling and exhaling quickly does not create the same protective mechanism as holding a deep breath.
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During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?
- A. Concave, midline umbilicus
- B. Pulsation between the umbilicus and pubis
- C. Bowel sound frequency of 15 sounds per minute
- D. Absence of a bruit
Correct Answer: B
Rationale: The correct answer is B because pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm (AAA), a serious condition that requires immediate medical attention. The pulsation in this area could be the enlargement of the aorta, which can be life-threatening if it ruptures. Reporting this finding to the physician is crucial for further evaluation and intervention.
Choice A (Concave, midline umbilicus) is incorrect because it is a normal finding during an abdominal assessment. Choice C (Bowel sound frequency of 15 sounds per minute) is incorrect as it falls within the normal range of bowel sounds. Choice D (Absence of a bruit) is also incorrect as the absence of a bruit is a normal finding and does not indicate any immediate concern.
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
- A. Having the client take rapid, shallow breaths to decrease pain.
- B. Having the client lay on the left side while coughing and deep breathing.
- C. Teaching the client to use a folded blanket or pillow to splint the incision.
- D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
Correct Answer: C
Rationale: The correct answer is C: Teaching the client to use a folded blanket or pillow to splint the incision. This measure helps support the incision site, reducing pain during coughing and deep breathing. Splinting the incision promotes effective coughing and deep breathing post-surgery, aiding in lung expansion and preventing complications like atelectasis.
Explanation of why other choices are incorrect:
A: Having the client take rapid, shallow breaths to decrease pain is incorrect as it can lead to inadequate lung expansion and retention of secretions.
B: Having the client lay on the left side while coughing and deep breathing is incorrect as it does not directly support the incision site and may not be as effective in reducing pain.
D: Withholding pain medication so the client can be alert enough to follow the nurse's instructions is incorrect as pain management is crucial post-surgery for comfort and optimal recovery.
The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which of the following items would the nurse include on this list?
- A. Fatty foods
- B. Nonfat milk
- C. Chocolate
- D. Coffee
Correct Answer: B
Rationale: The correct answer is B: Nonfat milk. Nonfat milk is alkaline and can help increase lower esophageal sphincter pressure, reducing reflux symptoms. Fatty foods (A) can relax the sphincter and worsen symptoms. Chocolate (C) and coffee (D) are known triggers for reflux and can also decrease sphincter pressure. Therefore, the nurse would include nonfat milk in the teaching to help manage symptoms of gastroesophageal reflux disease.
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.
Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication
- A. After meals.
- B. Mixed with fruit juice.
- C. Via rectal suppository.
- D. At least 3 hours before meals.
Correct Answer: B
Rationale: The correct answer is B: Mixed with fruit juice. Cholestyramine resin should be taken mixed with a liquid, such as fruit juice, to prevent esophageal irritation and improve absorption. Taking it with a meal can interfere with nutrient absorption. Taking it via rectal suppository is incorrect as it is an oral medication. Taking it at least 3 hours before meals is not necessary and may lead to decreased effectiveness. Mixing it with fruit juice helps improve tolerability and effectiveness.