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 D
Explanation
Choice A rationale
Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.
Choice B rationale
Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.
Choice C rationale
Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.
Choice D rationale
The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.
Correct Answer is B
Explanation
Choice A rationale
A tympanogram is a diagnostic test that measures the movement of the eardrum in response to changes in air pressure in the ear canal. It is used to assess the function of the middle ear and is not a part of the Weber's test. The Weber's test is a gross screening tool for hearing acuity that uses a vibrating tuning fork to compare bone conduction in both ears, not to evaluate middle ear function.
Choice B rationale
The Weber's test is a simple screening tool to detect unilateral hearing loss. The nurse places a vibrating tuning fork on the midline of the child's head, such as the forehead or the top of the head. The sound is transmitted through the skull bones to the inner ears. The child is asked where the sound is heard best—in the left ear, right ear, or equally in both. This assesses bone conduction.
Choice C rationale
The Weber's test evaluates whether the sound is heard equally in both ears or lateralizes to one ear, indicating a potential conductive or sensorineural hearing loss. It does not measure the duration of sound perception. Measuring the amount of time a client can hear the sound after the tuning fork is placed on the mastoid bone is part of the Rinne test, a different component of hearing assessment, which compares bone and air conduction.
Choice D rationale
Holding a vibrating tuning fork 1 to 2 cm from the ear canal is a procedure used for the Rinne test, not the Weber's test. The Rinne test compares air conduction to bone conduction. The vibrating tuning fork is placed first on the mastoid bone (bone conduction) and then near the ear canal (air conduction). This is used to distinguish between conductive and sensorineural hearing loss. *.
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