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 C

Explanation

Choice A reason: This test does not detect antithyroid antibodies in your blood. Antithyroid antibodies are proteins that atack the thyroid gland and can cause autoimmune thyroid diseases, such as Hashimoto’s thyroiditis or Graves’ disease. To detect antithyroid antibodies, you need a diﬀerent blood test called the thyroid peroxidase (TPO) antibody test.

Choice B reason: This test does not measure the amount of thyroid hormone that ataches to a protein in your blood. Thyroid hormone can exist in two forms in the blood: free or bound. Free thyroid hormone is not atached to any protein and can enter the cells and tissues where it is needed. Bound thyroid hormone is atached to a protein called thyroxine-binding globulin (TBG) and cannot enter the cells and tissues. To measure the amount of thyroid hormone that ataches to TBG, you need a diﬀerent blood test called the total thyroxine (T4) test.

Choice C reason: This test determines whether your thyroid gland is overactive, appropriately active, or underactive. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to make and release thyroid hormones, such as thyroxine (T4) and triiodothyronine (T3). These hormones regulate many body functions, such as metabolism, growth, and development. The TSH test measures the amount of TSH in the blood and reﬂects how well the thyroid gland is working. If the TSH level is high, it means that the thyroid gland is underactive (hypothyroidism) and not making enough thyroid hormones. If the TSH level is low, it means that the thyroid gland is overactive (hyperthyroidism) and making too much thyroid hormones.

Choice D reason: This test does not measure the absorption of iodine and how it relates to the thyroid gland. Iodine is a mineral that is essential for the production of thyroid hormones. The thyroid gland absorbs iodine from the food and water we consume and uses it to make T4 and T3. To measure the absorption of iodine by the thyroid gland, you need a diﬀerent test called the radioactive iodine uptake (RAIU) test.

A. Thyroxine (T4) level B. Triiodothyronine (T3) level C. Thyroid stimulating hormone (TSH) level D. Glucose level

Correct Answer is C

Explanation

Choice A: Thyroxine (T4) level. This is incorrect because T4 is one of the thyroid hormones that is increased in hyperthyroidism. T4 is produced by the thyroid gland and converted to T3 in the tissues. A high level of T4 indicates overactivity of the thyroid gland.1

Choice B: Triiodothyronine (T3) level. This is incorrect because T3 is another thyroid hormone that is increased in hyperthyroidism. T3 is the more active form of thyroid hormone and regulates the metabolism of cells. A high level of T3 indicates overactivity of the thyroid gland.1

Choice C: Thyroid stimulating hormone (TSH) level. This is correct because TSH is a hormone that stimulates the thyroid gland to produce T4 and T3. TSH is produced by the pituitary gland and regulated by a feedback mechanism. When the levels of T4 and T3 are high, the pituitary gland reduces the secretion of TSH to inhibit further production of thyroid hormones. Therefore, a low level of TSH indicates hyperthyroidism.1

Choice D: Glucose level. This is incorrect because glucose level is not directly related to thyroid function. However, hyperthyroidism can aﬀect glucose metabolism and cause increased blood sugar levels due to increased breakdown of glycogen and glucose uptake by cells. Therefore, glucose level may be elevated in some cases of hyperthyroidism, but it is not a specific indicator.

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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).

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A nurse is reinforcing teaching with a client who is scheduled for a blood test to measure her thyroid stimulating hormone (TSH) level. Which of the following statements should the nurse give?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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