Nokea
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
- A. To promote optimal ventilation
- B. To promote drainage from the abdominal cavity
- C. To prevent pressure sores from developing
- D. To reduce tension on the suture line
Correct Answer: B
Rationale: The semi-sitting position promotes gravity-dependent drainage through the Penrose drain from the abdominal cavity.
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The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
The client with hepatitis asks the nurse, 'I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?' Which statement is the nurse's best response?
- A. You are concerned about taking an herb.
- B. The herb has been used to treat liver disease.
- C. I would not take anything that is not prescribed.
- D. Why would you want to take any herbs?
Correct Answer: B
Rationale: Milk thistle is commonly used for liver support and may have hepatoprotective effects, though evidence is limited. This response provides accurate information without dismissing the client’s query.
The nurse is discharging the client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, which information should the nurse include in the client’s discharge instructions?
- A. Drink plenty of fluids with all your meals.
- B. Eat a high-carbohydrate, low-protein diet
- C. Wait to eat at least 5 hours between meals.
- D. Lie down for 20 to 30 minutes after meals.
Correct Answer: D
Rationale: A. Drinking fluids at mealtime increases the size of the food bolus that enters the stomach. B. Carbohydrates are more rapidly digested than fats and proteins and would cause the food bolus to pass quickly into the intestine, increasing the likelihood that dumping syndrome would occur. Meals high in carbohydrates result in postprandial hypoglycemia, which is considered a variant of dumping syndrome. C. Small, frequent meals are recommended to decrease dumping syndrome. D. Lying down after meals slows the passage of the food bolus into the intestine and helps to control dumping syndrome.
The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
- A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
- B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
- C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
- D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Correct Answer: D
Rationale: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.