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.
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. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ticks should not be removed by squeezing the body with tweezers, as this can cause the tick to regurgitate its stomach contents into the bloodstream, increasing the risk of infection transmission. The proper technique involves using fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pulling upward with steady pressure.
Choice B rationale
Testing for Lyme disease is not recommended immediately after a tick bite because the antibodies may not be detectable yet. The incubation period for the bacteria is several weeks. It is recommended to watch for symptoms and seek testing only if the characteristic bull's-eye rash or other symptoms develop, which typically occurs 3 to 30 days post-bite.
Choice C rationale
Using a product with DEET (N,N-diethyl-meta-toluamide) is a highly effective measure for preventing tick bites. DEET acts as a repellent that deters ticks and other insects from landing on the skin or clothing. It is a proven preventative strategy that significantly reduces the risk of contracting Lyme disease when walking in wooded or grassy areas.
Choice D rationale
Symptoms of Lyme disease, such as the characteristic erythema migrans (bull's-eye rash), typically appear within 3 to 30 days after being bitten by an infected tick. They do not appear within 2 days. The incubation period is a crucial factor in monitoring for the disease and seeking timely medical care if symptoms arise. .
Correct Answer is A
Explanation
Choice A rationale
For a preschooler, play is the primary mechanism for coping and learning. A pounding board allows the child to express frustration and aggression in a safe, appropriate manner. This type of play helps to relieve tension and anxiety associated with hospitalization. It provides a healthy outlet for emotions that the child may not be able to articulate verbally, which is crucial for this developmental stage.
Choice B rationale
Preschoolers have a limited understanding of complex language. Using medical terminology can be frightening and confusing to them, increasing their anxiety. Nurses should use simple, concrete language that the child can understand, such as "checking your arm" instead of "taking your blood pressure," to help them feel more secure and cooperative with care.
Choice C rationale
Preschoolers thrive on routine and predictability. Establishing a new routine can be disruptive and increase their stress and fear. The nurse should strive to maintain as much of the child's home routine as possible to provide a sense of security and normalcy. This helps them feel more in control and less overwhelmed by the hospital environment.
Choice D rationale
A preschooler may experience separation anxiety when a parent leaves the room. Performing assessments while the parent is present helps the child feel more secure and supported. The parent can also provide comfort and help distract the child, which can make procedures easier and less frightening for the child. This promotes a trusting relationship between the child, parent, and nurse.
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