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 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.
Correct Answer is C
Explanation
Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.
Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.
Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.
Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.
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