Nokea
The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment: Skin dry, Urine output 20/ml/hr, NG tube patent with 100/ml, brown drainage/hr, Restless; Vital Signs: Pulse: 128 beats/min, Blood pressure: 85/50 mm Hg, Respiratory rate: 20 on ventilator, Cardiac output: 2.1 l/min; Physician Orders: Normal saline at 75/ml/hr, Morphine sulfate 2 mg IV push every 1 hr, Vancomycin (Vancocin) 1 g IV every 8 hr. What action by the nurse is best?
- A. Administer the prescribed pain medication.
- B. Consult the surgeon about a different antibiotic.
- C. Consult the surgeon about increased IV fluids.
- D. Have respiratory therapy reduce the respiratory rate.
Correct Answer: C
Rationale: The client's vital signs, low urine output, dry skin, and low cardiac output indicate hypovolemia. Consulting the surgeon to increase IV fluids is the priority to address hypotension, rather than pain, antibiotics, or respiratory rate adjustments.
You may also like to solve these questions
A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first?
- A. Notify the surgeon.
- B. Put on a pair of gloves.
- C. Reinsert the NG reinsert the NG tube.
- D. Take a set of vital signs.
Correct Answer: B
Rationale: Standard precautions require putting on gloves first to protect the nurse from exposure to blood and body fluids. This is the priority before assessing vital signs, notifying the surgeon, or attempting to reinsert the NG tube.
A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?
- A. Client who underwent diverticula removal with a pulse of 106/min
- B. Client who had esophageal dilation and is attempting first postprocedure oral intake.
- C. Client who had an esophagectomy with a respiratory rate of 32/min
- D. Client who underwent hernia repair, reporting incisional pain of 7/10
Correct Answer: C
Rationale: A respiratory rate of 32/min post-esophagectomy suggests possible sepsis, a life-threatening condition requiring immediate assessment. The other clients' conditions (elevated pulse, oral intake, pain) are less urgent.
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 nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.)
- A. Chocolate
- B. Decaffeinated coffee
- C. Citrus fruits
- D. Peppermint
- E. Tomato sauce
Correct Answer: A,C,D,E
Rationale: Chocolate, citrus fruits, peppermint, and tomato-based products exacerbate GERD by promoting reflux. Decaffeinated coffee is less likely to trigger symptoms compared to caffeinated beverages.
The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assisting with position changes and getting out of bed
- B. Keeping the head of the bed elevated to at least 30
- C. Turning the client
- D. Reminding the client to use the spirometer every 4 hours
- E. Taking and recording vital signs per hospital protocol
- F. Titrating oxygen based on the client oxygen saturations
Correct Answer: A,B,D
Rationale: UAPs can assist with mobility, maintain bed elevation, and remind about spirometer use (though it should be every 1-2 hours). Oxygen titration requires nursing judgment and cannot be delegated.