Nokea
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
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The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
During a clinic visit the client provides all of the following health history information. Which client statement should be most concerning to the nurse because it could describe a symptom of esophageal cancer?
- A. “I have been having a lot of indigestion lately.”
- B. “When I eat meat, it seems to get stuck halfway down.”
- C. “I have been waking up at night lately with chest pain.”
- D. “I gained weight, even though I have not changed my diet.”
Correct Answer: B
Rationale: A. Indigestion is not a symptom of esophageal cancer. B. Progressive dysphagia is the most common symptom associated with esophageal cancer, and it is initially experienced when eating meat. It is often described as a feeling that food is not passing. C. Chest pain is not a symptom of esophageal cancer. D. Weight loss rather than gain is a symptom of esophageal cancer.
The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis?
- A. My pain goes away when I have a bowel movement.
- B. I have bright red blood in my stool all the time.
- C. I have episodes of diarrhea and constipation.
- D. My abdomen is hard and rigid and I have a fever.
Correct Answer: C
Rationale: Crohn's disease often causes alternating diarrhea and constipation due to inflammation and strictures throughout the GI tract. Pain relief after bowel movements is less specific, bright red blood is more typical of ulcerative colitis, and a rigid abdomen suggests complications.
The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.