Nokea
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.
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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.
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.
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 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.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.
- A. Encourage the client to eat frequent, small, well-balanced meals.
- B. Inform the client to remain upright for at least 2 hours after meals.
- C. Encourage the client to eat later in the day before bedtime rather than early in the morning.
- D. Instruct the client to avoid alcohol or tobacco products.
- E. Instruct the client to eat slowly and chew the food thoroughly.
Correct Answer: A,B,D,E
Rationale: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.