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 reason: Shock is not a cause of acute pancreatitis, but a possible complication of severe cases that can lead to organ failure and death.

Choice B reason: Gallstones are one of the major causes of acute pancreatitis, as they can block the pancreatic duct and prevent the ﬂow of digestive enzymes, leading to inﬂammation and damage of the pancreas.

Choice C reason: Diabetes mellitus is not a cause of acute pancreatitis, but a possible complication of chronic pancreatitis, as the damage to the pancreas can impair its ability to produce insulin and regulate blood sugar levels.

Choice D reason: GERD (gastroesophageal reﬂux disease) is not a cause of acute pancreatitis, but a condition that aﬀects the lower esophageal sphincter and allows stomach acid to reﬂux into the esophagus, causing heartburn and other symptoms.

A. “I will feel shaky.” B. “My skin will be warm and moist.” C. “I will be more thirsty than usual.” D. “My appetite will be decreased.”

Correct Answer is A

Explanation

Choice A: “I will feel shaky.” This is a correct statement, as shakiness is a common manifestation of hypoglycemia, which is a low blood glucose level. Hypoglycemia can cause the sympathetic nervous system to release adrenaline, which can cause tremors, nervousness, and anxiety.

Choice B: “My skin will be warm and moist.” This is an incorrect statement, as warm and moist skin is not a typical manifestation of hypoglycemia. Warm and moist skin can be a sign of hyperglycemia, which is a high blood glucose level. Hyperglycemia can cause dehydration, which can lead to sweating and ﬂushing.

Choice C: “I will be more thirsty than usual.” This is an incorrect statement, as thirst is not a typical manifestation of hypoglycemia. Thirst can be a sign of hyperglycemia, which can cause dehydration, as the body tries to ﬂush out excess glucose through urine.

Choice D: “My appetite will be decreased.” This is an incorrect statement, as decreased appetite is not a typical manifestation of hypoglycemia. Decreased appetite can be a sign of other conditions, such as nausea, infection, or depression. Hypoglycemia can cause increased hunger, as the body needs more glucose to function properly.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client’s history?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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).

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

A nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and reporting feeling lightheaded and shaky. Which of the following complications should the nurse suspect?

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A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been eﬀective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.)