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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.
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The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply.
- A. Do not use if the client has a heart block or prolonged QT interval.
- B. Increases sedation if used with opiates.
- C. Emphasize prevention. The client must take consistently to prevent nausea and vomiting.
- D. Explain that it must be started before travel to be effective.
- E. Explain that there is a risk for dehydration.
Correct Answer: A,B,C
Rationale: When administering ondansetron to an older adult client, the nurse should take extra care to consider safety warnings that advise the nurse to avoid use if a client has a heart block or prolonged QT interval, and should also be mindful that the medication can increase sedation when used with opiates. In addition, the nurse should adhere to guidelines instructing an emphasis on prevention for the client, the older adult client must take the medication consistently to prevent nausea and vomiting. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. The early stage of oral cancer is characteristically asymptomatic.
- B. A lesion, lump, or other abnormality may be present on the lips or mouth.
- C. Difficulty eating or tasting food may occur.
- D. Pain and numbness are typically present.
- E. Persistent hoarseness is a hallmark sign.
Correct Answer: A,B
Rationale: The nurse should inform the client that oral cancer is characteristically asymptomatic in its early stage, though lesions, lumps, or other abnormalities may be present on the lips and mouth. While it is true that oral cancer may cause difficulty eating or tasting food, pain and numbness, and persistent hoarseness, these events occur later in the disease's progression and are not relevant in discussion of the early stage.
A client who is recovering from bariatric surgery is returning from the postanesthesia care unit. Which nursing assessment finding is of greatest concern in the immediate postoperative period for this client?
- A. Impaired Gas Exchange
- B. Self-Care Deficit
- C. Impaired Mobility
- D. Diarrhea
Correct Answer: A
Rationale: Extremely obese clients are at greater risk for complications related to anesthesia and surgery. Obstructive sleep apnea and impaired breathing can be a problem requiring continuous or positive airway pressure devices. Self-care deficit and impaired mobility are real problems that need to be addressed but less significant than airway issues. Diarrhea due to dumping syndrome is not an immediate post-op issue.
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.
A nurse is providing discharge teaching for a client following Roux-En-Y (RYGB) surgery. What instruction(s) should the nurse include in the teaching? Select all that apply.
- A. Stop eating when you feel full.
- B. Avoid all sweets.
- C. Choose breads, cereals, and grains that provide less than 2 g of fiber per serving.
- D. Limit mealtimes to fewer than 45 minutes.
- E. Begin with five to six meals a day.
Correct Answer: A,B,C
Rationale: The nurse should instruct the client to stop eating when the client feels full, avoid all sweets, and choose breads, cereals, and grains that provide less than 2 g of fiber per serving. The client should plan to take an hour to eat, chewing food slowly and thoroughly. The client should not begin with five to six meals a day but should instead gradually progress to this number of meals.