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The nurse is caring for a client with anorexia and constipation due to reduced bulk in the diet and the use of liquid supplements. Which intervention(s) should the nurse include in the plan of care for the client? Select all that apply.
- A. Keep a record of the client's bowel movements.
- B. Consult with the health care provider and dietitian about changing the type of supplement.
- C. Dilute the formula until the client adjusts to the concentrated contents.
- D. Administer a prescribed stool softener.
- E. Assist the client and dietitian to decrease dietary fiber.
Correct Answer: A,B,C,D
Rationale: The nurse should keep a record of the client's bowel movements, consult with the health care provider and dietitian about changing the type of supplement, dilute the formula until the client adjusts to the concentrated contents, and administer a prescribed stool softener. Dietary fiber should be increased, not decreased, as a decrease will further reduce the amount of bulk in the client's diet and contribute to further constipation.
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The nurse is managing the care of a client needing gastrointestinal suction and decompression with a Levin tube. Place the steps of initiating suction and decompression in the order the nurse should perform them.
- A. Insert the gastric decompression tube.
- B. Locate the suction source.
- C. Connect the decompression tube to the suction.
- D. Select suction according to health care provider prescription.
Correct Answer: B,D,A,C
Rationale: The nurse should locate the suction source, usually a wall outlet or portable machine. The nurse should then adjust the suction level on the wall outlet or portable machine to provide the amount and frequency of suction specified by the primary provider. The nurse should select intermittent high, low, or continuous suction when using a Salem sump tube; the nurse should select low intermittent suction when using a Levin tube because the single lumen may adhere to the lining of the stomach during continuous suction (if the tube is used only to obtain specimens for diagnostic purposes, manual suction may be achieved by attaching a syringe to the end of the tube and drawing back on the plunger). Finally, the nurse should insert the gastric decompression tube in accordance with accepted standards and connect it to the suction.
The nurse is caring for a client with hypovolemia related to prolonged vomiting and decreased intake of oral fluids. What activity(ies) should the nurse include in the client's plan of care? Select all that apply.
- A. Encourage the client to drink a 16 oz (480 mL) glass of water over the course of 15 minutes.
- B. Instruct the client to avoid beverages with additives such as electrolytes.
- C. Inform the primary provider if urine output is 3.5 oz (100 mL) per day or lower.
- D. Monitor weight daily.
- E. Assess skin turgor and mucous membranes.
Correct Answer: D,E
Rationale: The nurse should monitor the client's weight daily and assess skin turgor and mucous membranes. The nurse should offer clear liquids in small amounts. Slow introduction of fluids enables the client to develop tolerance and determine if it is possible to advance the diet. The nurse should recommend the use of commercial, over-the-counter beverages that contain electrolytes. If the client's urine output drops below 17 oz (500 mL) per day, the nurse should notify the primary provider because this indicates severe dehydration and the need for IV replacement fluids.
Which assessment finding is most indicative of dumping syndrome in a postgastrectomy client?
- A. Abdominal distention, elevated temperature, weakness before eating
- B. Constipation, rectal bleeding following bowel movements
- C. Persistent loose stools, chills, hiccups after eating
- D. Weakness, diaphoresis, diarrhea 90 minutes after eating
Correct Answer: D
Rationale: Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
A client who has recovered from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort?
- A. Keeping the head of the bed elevated.
- B. Positioning the client flat on the abdomen or side.
- C. Providing a tracheostomy tray near the bed.
- D. Turning the client's head to the side.
Correct Answer: A
Rationale: It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth until the client has recovered from anesthesia. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response?
- A. I can arrange a nutritional consultation.
- B. Cold liquids may help soothe the sensitivity.
- C. An anesthetic mouthwash may be used, but I will need to consult with the primary provider.
- D. A special diet may be necessary based on your ability to chew and swallow.
- E. Your doctor may prescribe a systemic analgesic for pain relief if necessary.
Correct Answer: A,C,D,E
Rationale: When responding to a client reporting severe mouth sensitivity due to oral cancer, the nurse should inform the client of possible options for managing the sensitivity. These include nutritional consultations, the use of anesthetic mouthwash if approved by the primary provider, the formulation of a special diet around the client's ability to chew and swallow, and a systemic analgesic for pain relief if the provider deems it necessary. It is inaccurate for the nurse to respond that cold liquids may soothe the sensitivity, because cold and hot liquids may increase the discomfort of sensitive oral tissues.