When providing nursing care for a client after a gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?
Sore throat.
Headache.
Aching leg.
Nausea.
The Correct Answer is A
Choice A rationale
After a gastric endoscopy, it’s common for patients to experience a sore throat. This is due to the passage of the endoscope through the throat during the procedure. The discomfort is usually temporary and can be relieved with lozenges or gargling with warm salt water.
Choice B rationale
While headaches can occur after procedures that involve sedation, they are not commonly associated with gastric endoscopy specifically. Therefore, while it’s important to monitor for headaches, they are not a typical post-procedure problem following a gastric endoscopy.
Choice C rationale
Aching legs are not a common problem following a gastric endoscopy. The procedure primarily involves the upper gastrointestinal tract, and does not directly affect the legs.
Choice D rationale
Nausea can occur after a gastric endoscopy, but it is more commonly associated with the sedation used during the procedure rather than the procedure itself. If nausea does occur, it can be managed with antiemetic medications.
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Correct Answer is C
Explanation
Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.
Correct Answer is ["100"]
Explanation
Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.
Step 2: We need to find the infusion pump’s regulation in mL/hour.
Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.
Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).
Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.
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