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 A
Explanation
Choice A rationale
Applying petroleum jelly to the glans of the penis is an important step in the care of a newborn who has undergone a Gomco circumcision. This acts as a protective barrier to prevent the glans from sticking to the diaper, which can cause pain and disrupt the healing process. This is done with each diaper change for the first few days.
Choice B rationale
The yellow, sticky exudate that forms on the glans is a normal part of the healing process and is composed of fibrin and serum. Wiping it off can disrupt the healing tissue and increase the risk of bleeding and infection. The parent should be instructed to allow this exudate to fall off naturally.
Choice C rationale
Applying gentle pressure with a diaper is not an appropriate intervention. The area should be kept as free from pressure as possible to promote healing and reduce discomfort. Pressure could cause bleeding, pain, or damage to the delicate new tissue that is forming.
Choice D rationale
Alcohol is a harsh astringent that can cause significant pain and irritation to the sensitive, healing tissue of the glans. It can also dry out the skin, delaying the healing process. Only warm water should be used to clean the area during diaper changes. .
Correct Answer is A
Explanation
Choice A rationale
Beginning ball-squeezing exercises is a correct instruction. These exercises, along with others like wall climbing, are essential to promote lymphatic drainage and restore range of motion in the arm on the affected side. Starting these early helps prevent the development of lymphedema, a common complication of mastectomy, by facilitating circulation and reducing fluid accumulation.
Choice B rationale
Wearing a bra with wire support is incorrect. Post-mastectomy, a client should be advised to wear a soft, supportive, and non-restrictive bra, preferably without underwire. Underwire can cause pressure and irritation on the incision site, potentially delaying healing and increasing the risk of lymphedema by compressing lymphatic vessels, which impedes the proper flow of lymph.
Choice C rationale
Avoiding using the affected arm for eating is incorrect. Gentle use of the affected arm for activities of daily living, such as eating and dressing, is encouraged early on to promote mobility and prevent stiffness. The key is to avoid strenuous activities and heavy lifting, but using the arm for routine tasks is beneficial for maintaining function and promoting recovery.
Choice D rationale
Using deodorant under the affected arm is incorrect. After a modified radical mastectomy, the client should be advised to avoid applying deodorant, lotions, or creams to the axilla on the surgical side. The skin in this area is often sensitive and prone to irritation, and these products can introduce bacteria, increasing the risk of infection and interfering with the healing process of the surgical site. .
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