A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply).

Document the color, consistency, and amount of nasogastric drainage.

Encourage hourly use of an incentive spirometer while awake.

Irrigate the nasogastric tube every 4 to 8 hr.

Perform leg exercises every 2 hr.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Documenting the color, consistency, and amount of nasogastric drainage is an important action for the nurse to include in the client’s plan of care. This can help monitor the client’s GI function, ﬂuid balance, and response to treatment. The normal color of nasogastric drainage is clear or yellow-green. Abnormal colors include red, brown, or black, which may indicate bleeding.

Choice B reason: Encouraging hourly use of an incentive spirometer while awake is an important action for the nurse to include in the client’s plan of care. This can help prevent respiratory complications, such as atelectasis and pneumonia, which are common after abdominal surgery. An incentive spirometer is a device that helps the client breathe deeply and expand the lungs.

Choice C reason: Irrigating the nasogastric tube every 4 to 8 hr is not an action that the nurse should include in the client’s plan of care. Routine irrigation of nasogastric tubes is not recommended, as it may increase the risk of infection, tube occlusion, or aspiration. Irrigation should only be done when indicated by specific orders or protocols, or when there is evidence of tube blockage.

Choice D reason: Performing leg exercises every 2 hr is an important action for the nurse to include in the client’s plan of care. This can help prevent venous thromboembolism (VTE), which is a serious complication that can occur after surgery due to immobility and hypercoagulability. Leg exercises can improve blood circulation and reduce stasis in the lower extremities.

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Correct Answer is B

Explanation

Choice A: “I put lotion between my toes.” This is incorrect because putting lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the tops and botoms of the feet, but avoid the areas between the toes.

Choice B: “I check my feet every day for sores and bruises.” This is correct because checking the feet every day for any signs of injury, infection, or ulceration is an important part of foot care for a client who has diabetes mellitus. The client should also report any problems to the provider and seek prompt treatment.

Choice C: “I wear sandals in warm weather.” This is incorrect because wearing sandals can expose the feet to injury, sunburn, or insect bites. The client should wear closed-toe shoes that fit well and protect the feet from trauma and environmental hazards.

Choice D: “I soak my feet in warm, soapy water every night before I go to bed.” This is incorrect because soaking the feet can cause maceration of the skin and increase the risk of infection. The client should wash the feet with mild soap and warm water, but not soak them. The client should also dry the feet thoroughly, especially between the toes.

A. Sensitivity to cold B. Frequent mood changes C. Weight gain D. Constipation

Correct Answer is B

Explanation

Choice A: Sensitivity to cold. This is incorrect because sensitivity to cold is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and heat production, which makes them more sensitive to heat.

Choice B: Frequent mood changes. This is correct because frequent mood changes are a manifestation of hyperthyroidism. Clients with hyperthyroidism have increased levels of thyroid hormones, which can aﬀect their nervous system and cause irritability, anxiety, nervousness, or emotional instability.

Choice C: Weight gain. This is incorrect because weight gain is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and appetite, which makes them lose weight or have difficulty gaining weight.

Choice D: Constipation. This is incorrect because constipation is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased bowel motility and peristalsis, which makes them more prone to diarrhea or frequent stools.

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A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply).

Nursing Test Bank

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Correct Answer is B

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Correct Answer is B

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