Nokea
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.
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A client is 1 day postoperative after having Zanders diverticula removed. The client has a nasogastric (NG) tube in place. The NG tube is not being used for suctioning drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate?
- A. Document the findings as normal.
- B. Irrigate the NG tube with sterile saline.
- C. Notify the surgeon about this finding.
- D. Remove and reinsert the NG tube.
Correct Answer: C
Rationale: NG tubes placed during surgery should not be manipulated without surgeon orders. Lack of suction or drainage is not normal and requires notifying the surgeon for further evaluation, as irrigation or reinsertion could be harmful.
A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best?
- A. Arrange an intensive care unit tour.
- B. Assess the client's psychosocial status.
- C. Document the teaching and response.
- D. Have the client begin nutritional supplements.
Correct Answer: B
Rationale: Clients facing esophagogastrostomy are often anxious due to the procedure's complexity. Assessing psychosocial status is critical to address anxiety and provide tailored support, making it the best action compared to the more limited scope of the other options.
A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client?
- A. Famotidine (Pepcid)
- B. Magnesium hydroxide
- C. Omeprazole (Prilosec)
- D. Ranitidine (Zantac)
Correct Answer: C
Rationale: Omeprazole is a proton pump inhibitor used for GERD. Famotidine and ranitidine are histamine blockers, and magnesium hydroxide is an antacid, none of which are proton pump inhibitors.
A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching?
- A. After the operation I can eat anything I want.
- B. I will have to eat smaller, more frequent meals.
- C. I will take stool softeners for several weeks.
- D. This surgery may not totally control my symptoms.
Correct Answer: A
Rationale: Nutritional and lifestyle changes must continue after fundoplication, as it does not offer a lifetime cure. The other statements reflect accurate understanding of postoperative expectations.
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.