A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.

Chill the lavage fluid before instilling it.

Position the client on his right side.

Withdraw the fluid manually until it is clear.

Insert a small-bore NG tube.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Chilling the lavage fluid causes vasoconstriction of the gastric blood vessels, which helps to slow or stop the bleeding. The cold temperature directly constricts the capillaries and arterioles in the stomach lining, reducing blood flow to the bleeding site. This action is a primary goal of gastric lavage in cases of upper gastrointestinal hemorrhage.

Choice B rationale

Positioning the client on their left side is the appropriate action. This position allows the lavage fluid to pool in the greater curvature of the stomach, where it can be most effective at washing over the bleeding site. Placing the client on their right side would cause the fluid to quickly pass into the duodenum, which is less effective for gastric lavage.

Choice C rationale

Gastric lavage is performed to remove blood and clots from the stomach. The procedure involves instilling a fluid, typically saline, and then withdrawing it. The nurse continues this process, manually withdrawing the fluid, until the return fluid is clear or only slightly pink, which indicates that the bleeding has been controlled or significantly reduced.

Choice D rationale

A large-bore NG tube (16-18 French or larger) is preferred for gastric lavage in cases of upper gastrointestinal bleeding. A large-bore tube is necessary to effectively remove blood clots and viscous fluid from the stomach. A small-bore tube would easily become occluded by clots, rendering the lavage procedure ineffective. *.

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Correct Answer is A

Explanation

Choice A rationale

Spina bifida is associated with a high incidence of latex allergy due to repeated surgical procedures and catheterizations. There is a documented cross-reactivity between latex proteins and certain food proteins, particularly those found in bananas, avocados, kiwis, and chestnuts. These foods share similar antigenic determinants.

Choice B rationale

Strawberries are not typically associated with latex cross-reactivity. While they can cause allergic reactions in some individuals, the proteins responsible for these allergies do not share the same antigenic structures as those found in natural rubber latex. Therefore, a latex allergy does not necessarily predict a strawberry allergy.

Choice C rationale

Almonds are a tree nut, and while tree nut allergies are common, they are not typically linked to latex cross-reactivity. The allergenic proteins in almonds, such as the major protein Amandin, are structurally different from the proteins found in natural rubber latex, minimizing the risk of a cross-reaction.

Choice D rationale

Hazelnuts, like almonds, are a type of tree nut and are not generally known for cross-reactivity with latex. The proteins that trigger hazelnut allergies do not share significant homology with the proteins in natural rubber latex, so there is no established correlation between a latex allergy and a hazelnut allergy. .

A. Heartburn. B. Abdominal cramping. C. Breathlessness. D. Constipation.

Correct Answer is A

Explanation

Choice A rationale

A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up into the chest through the diaphragm's esophageal hiatus. This displacement disrupts the lower esophageal sphincter's function, causing gastric acid to reflux into the esophagus and resulting in heartburn.

Choice B rationale

Abdominal cramping is typically associated with conditions affecting the intestines, such as irritable bowel syndrome, inflammatory bowel disease, or bowel obstruction. It is not a direct symptom of a sliding hiatal hernia, which primarily affects the stomach and esophagus.

Choice C rationale

Breathlessness or dyspnea can be a symptom of a very large hiatal hernia that compresses the lungs. However, for a standard sliding hiatal hernia, it is not a primary or expected finding. The most common manifestation is related to acid reflux.

Choice D rationale

Constipation is a condition of the large intestine and is characterized by infrequent bowel movements. It is not directly caused by a sliding hiatal hernia, as the hernia’s primary impact is on the stomach and esophagus, causing upper gastrointestinal symptoms. *.

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A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take.

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A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.