A nurse is caring for an older adult patient who has had surgery for an intestinal obstruction and has an NG tube to wall suction.
Which of the following interventions should the nurse include in the patient's postoperative plan of care? (Select all that apply)
Encourage the use of an incentive spirometer every 2 hours while the client is awake.
Discontinue suction when assessing for peristalsis.
Place sequential compression devices on the bilateral lower extremities.
Reposition the patient from side to side every 2 hours.
Correct Answer : A,C,D,E
Choice A rationale
Postoperative patients, especially those with NG tubes and abdominal surgery, are at risk for atelectasis and pneumonia. Using an incentive spirometer every two hours while awake helps to promote lung expansion, clear secretions, and prevent respiratory complications by encouraging deep breathing.
Choice B rationale
To assess for peristalsis, the nurse must listen for bowel sounds. The continuous noise from the wall suction will obscure the bowel sounds, making an accurate assessment impossible. Therefore, the nurse must temporarily clamp or turn off the suction to auscultate the abdomen for bowel sounds.
Choice C rationale
Intestinal obstruction surgery and the presence of an NG tube can lead to immobility and venous stasis, increasing the risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). Sequential compression devices promote venous return and are a critical intervention for DVT prophylaxis.
Choice D rationale
Repositioning the patient from side to side every two hours helps to prevent skin breakdown and pressure ulcers, which are risks for all bedridden patients. It also aids in promoting lung expansion and prevents atelectasis by allowing for better ventilation and perfusion in different lung areas.
Choice E rationale
The NG tube can become clogged with gastric contents, preventing adequate decompression. Irrigating the tube with 0.9% sodium chloride helps to maintain patency and ensure that the suction continues to remove stomach secretions, which is crucial for relieving pressure and preventing distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A serum sodium level of 114 mEq/L indicates severe hyponatremia. The normal range for serum sodium is 135 to 145 mEq/L. SIADH is characterized by an excessive release of ADH, leading to water retention and dilutional hyponatremia. Increasing dietary sodium would not correct the underlying fluid imbalance and could potentially worsen the condition by causing further fluid shifts.
Choice B rationale
Fluid restriction is the primary treatment for SIADH and is crucial for managing dilutional hyponatremia. By restricting fluid intake to 500 to 1000 mL/day, the nurse helps to correct the water imbalance and increase serum sodium concentration. This action directly addresses the pathophysiology of SIADH, which is characterized by water retention.
Choice C rationale
While measuring intake and output is important for monitoring a patient with SIADH, it is a monitoring action, not a primary intervention to correct the sodium imbalance. The instruction to assistive personnel to perform this task is part of standard care but does not address the critical need for fluid restriction in a patient with severe hyponatremia.
Choice D rationale
Gentle handling is a precaution for patients with hyponatremia due to the risk of cerebral edema and seizure activity. However, it is not the most appropriate nursing action to address the underlying physiological problem of fluid retention and low serum sodium. Fluid restriction is the priority action to correct the fluid imbalance and prevent complications.
Correct Answer is D
Explanation
For a patient who is lethargic but able to follow simple instructions, the first action is to provide a fast-acting carbohydrate. Fruit juice is a quick source of glucose that can be rapidly absorbed to raise the patient's blood sugar level. The American Diabetes Association recommends providing 15-20 grams of glucose or a simple carbohydrate, like 4 oz of fruit juice, as the initial treatment for hypoglycemia in a conscious patient.
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