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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Both illnesses result in malabsorption of nutrients. This is incorrect because malabsorption of nutrients is more common in Crohn’s disease than in ulcerative colitis. Crohn’s disease can affect any part of the gastrointestinal tract, including the small intestine, where most of the nutrient absorption occurs. Ulcerative colitis mainly affects the colon and rectum, which are responsible for water and electrolyte absorption.
Choice B: Both illnesses begin in the rectum. This is incorrect because ulcerative colitis usually begins in the rectum and spreads proximally to the colon, while Crohn’s disease can begin anywhere in the gastrointestinal tract, from the mouth to the anus.
Choice C: Both illnesses manifest fistula formation. This is incorrect because fistula formation is more common in Crohn’s disease than in ulcerative colitis. Fistulas are abnormal connections between different parts of the gastrointestinal tract or other organs, such as the bladder, vagina, or skin. They are caused by inflammation, ulceration, and infection that penetrate through the bowel wall.
Choice D: Both illnesses are inflammatory in nature. This is correct because both ulcerative colitis and Crohn’s disease are types of inflammatory bowel disease (IBD), which are chronic conditions that cause inflammation and damage to the gastrointestinal tract. The exact cause of IBD is unknown, but it may involve genetic, immune, environmental, and microbial factors.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Tachycardia is a common symptom of hypoglycemia, as the body releases adrenaline and other hormones to raise the blood sugar level. This can cause the heart to beat faster and stronger.
Choice B reason: Blurry vision is a common symptom of hypoglycemia, as low blood sugar can affect the ability of the eyes to focus and see clearly. This can also cause headaches, dizziness, or double vision.
Choice C reason: Sweating is a common symptom of hypoglycemia, as the body tries to cool down and cope with the stress of low blood sugar. This can also cause shakiness, trembling, or tingling in the lips, tongue, or cheek.
Choice D reason: Polydipsia (excessive thirst) is not a symptom of hypoglycemia, but a symptom of hyperglycemia (high blood sugar). High blood sugar can cause dehydration and dry mouth, which make the person feel thirsty.
Choice E reason: Polyuria (excessive urination) is not a symptom of hypoglycemia, but a symptom of hyperglycemia (high blood sugar). High blood sugar can cause the kidneys to filter out excess glucose and water from the blood, which make the person urinate more often.
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