Nokea
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.
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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.
A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?
- A. Remove the tube and reinsert when the respiratory distress subsides.
- B. Pull back on the tube and wait until the respiratory distress subsides.
- C. Quickly insert the tube.
- D. Notify the physician immediately.
Correct Answer: B
Rationale: The correct answer is B: Pull back on the tube and wait until the respiratory distress subsides. This action allows for the nurse to relieve the pressure on the airway caused by the nasogastric tube, potentially alleviating the client's difficulty in breathing. It is important to prioritize the client's respiratory status and ensure they can breathe comfortably before proceeding with the procedure.
A: Removing the tube may worsen the respiratory distress and delay appropriate intervention.
C: Quickly inserting the tube can further compromise the client's breathing and cause more distress.
D: While notifying the physician is important, immediate intervention to address the breathing difficulty is crucial before seeking further assistance.
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.
A nurse teaches a preoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states
- A. When my gastrointestinal system is healed enough.
- B. When I can tolerate food without vomiting.
- C. When my bowels begin to function again, and I begin to pass gas.
- D. When the doctor says so.
Correct Answer: C
Rationale: The correct answer is C. The rationale is as follows: The return of bowel function, evidenced by passing gas, is an important indicator of gastrointestinal motility and recovery postoperatively. It indicates that the gastrointestinal system is beginning to function normally, which is a key factor in determining when the nasogastric tube can be safely removed. Choices A and B are too general and do not provide a specific physiological indicator for tube removal. Choice D defers the decision solely to the doctor without considering the client's physiological progress. Therefore, the most appropriate and accurate indicator for tube removal is the return of bowel function and passage of gas, as stated in option C.
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.