A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient’s NG tube and initiates oral feedings.
Which of the following statements should the nurse make?

 

 

Choice A rationale

Orlistat works by inhibiting the absorption of dietary fats in the body, which are then excreted in the stool. One of the side effects of this process can be changes in bowel habits, including an increase in the frequency of bowel movements and an oily discharge. Dark urine can be a sign of liver damage, which is a rare but serious side effect of orlistat. Therefore, if a patient notices their urine getting darker in color while taking orlistat, they should stop taking the medication and call their doctor immediately.

Choice B rationale

Orlistat should be taken with a meal that contains fat, not necessarily before breakfast. If a meal is missed or contains no fat, the dose of orlistat should be skipped.

Choice C rationale

Orlistat does not directly affect hunger signals or the feeling of fullness. It works in the digestive system to block about one-third of the fat in the food you eat from being digested.

Choice D rationale

While it’s important to maintain a balanced, reduced-calorie diet while taking orlistat, a no-fat diet is not recommended. Orlistat works by blocking the absorption of some of the fat from meals. If a meal contains no fat, there is no fat for orlistat to block.

Choice A rationale

The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.

Choice B rationale

Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.

Choice C rationale

Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.

Choice D rationale

Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.