The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?

Promptly assess the client for a potential perforation

Tell the assistant to change thermometers and retake the temperature

Plan to give the client acetaminophen the lower temperature

Ask the assistant to bathe the client with tap water

Answer and Explanation

The Correct Answer is A

A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. It is appropriate to notify the physician if bright red blood is found in the NG tube, as this could indicate bleeding, which requires prompt medical attention.
B. It is standard practice to keep the NG tube taped and secured to the patient’s nares to prevent dislodgement and ensure proper function.
C. A temperature under 100.5°F is generally not a cause for concern postoperatively, unless it is persistent or accompanied by other signs of infection. Typically, a low-grade fever is expected after surgery, but further investigation is only warranted for higher fevers or other concerning symptoms.
D. Irrigating the NG tube every 6 hours with 30 mL of normal saline is standard practice to ensure patency of the tube and prevent clogging.

A. Fever and chills B. Shakiness and diaphoresis C. Excessive thirst and urination D. Hypertension and crackles

Correct Answer is B

Explanation

A. Fever and chills are often indicative of infection, which may be a concern with TPN, but they are not typically the immediate concern if the TPN solution is not infusing.
B. Shakiness and diaphoresis (sweating) can occur due to hypoglycemia, which is a potential consequence of an interrupted TPN infusion. TPN provides glucose to the client, and a disruption in the infusion could cause a drop in blood sugar, leading to shakiness and diaphoresis.
C. Excessive thirst and urination are common symptoms of hyperglycemia or diabetes, but they are not typically seen with an interrupted TPN infusion.
D. Hypertension and crackles are more related to fluid overload or heart failure, which would not be an immediate concern in the case of an infusion pump malfunction for TPN.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a nasogastric (NG) tube following esophagectomy. Following standards of practice, which of the following postoperative instructions should the nurse question the surgeon about?

Correct Answer is C

Explanation

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Correct Answer is B

Explanation

As a result of gastric resection, the client is at risk for developing dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes?

A nurse is teaching student nurses about different types of medical conditions that affect the gastrointestinal system, when a student asks her about the cause of esophageal varices. What is an appropriate answer by the nurse when asked about a potential cause of esophageal varices?

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

A client comes to the clinic complaining of dysphagia and states that "he feels like food is stuck in his throat." The physician suspects esophageal cancer. Which of the following is a risk factor for esophageal cancer?