A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

To promote digestion

To regulate blood pressure

To reduce inflammation

To enhance the immune system

Answer and Explanation

The Correct Answer is A

A.   Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B.   Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C.   Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D.   Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.

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Correct Answer is A

Explanation

A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.

A. Place the client in a high Fowler's position. B. Ambulate the client twice daily. C. Mark abdominal girth once daily. D. Irrigate the nasogastric tube with tap water.

Correct Answer is C

Explanation

A. Place the client in a high Fowler's position:High Fowler’s would increase intra-abdominal pressure and strain sutures. For peritonitis recovery, semi-Fowler’s is preferred-promotes drainage of peritoneal fluid into the pelvis, preventing spread to diaphragm and lungs.

B. Ambulate the client twice daily:Too early after peritonitis lavage. Initially, the client is very weak, at risk for sepsis/shock. Early ambulation is not a priority here.

C. Mark abdominal girth once daily:Abdominal girth measurement is important to monitor for distention, fluid accumulation, or bleeding. Marking ensures accuracy in repeated measurements. This is a key intervention in monitoring postop peritonitis.

D. Irrigate the nasogastric tube with tap water:Never irrigate with tap water (risk of electrolyte imbalance, infection). Only sterile normal saline or as prescribed is used.

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A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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