The nurse is providing care for a patient who had surgical repair of a paraesophageal (rolling) hernia. The nurse observes that the patient is having difficulty swallowing during the first postoperative meal.What action should the nurse take?

Assure the patient the problem is temporary.

Cut the food into small pieces.

Report the observation to the healthcare provider (HCP).

Offer the patient liquids instead.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Assuring the patient that the problem is temporary may not be accurate. Postoperative dysphagia could indicate a complication from the surgery, such as the stomach fundus being wrapped too tight around the esophagus, causing food obstruction. It’s important to not dismiss the patient’s concerns without proper assessment.
Choice B rationale
Cutting the food into small pieces might help the patient swallow easier, but it does not address the underlying issue. The patient’s difficulty in swallowing could be a sign of a serious problem that needs medical attention.
Choice C rationale
Reporting the observation to the healthcare provider (HCP) is the correct action. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction.
Choice D rationale

Offering the patient liquids instead might alleviate the symptom temporarily, but it does not solve the potential problem. The healthcare provider needs to be informed about the dysphagia to assess and treat the possible complication.

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Correct Answer is C

Explanation

Choice A rationale
This statement indicates fatigue and lack of energy, which are common symptoms in patients with end-stage liver cancer. However, it does not necessarily indicate denial.
Choice B rationale

This statement suggests acceptance rather than denial. The patient acknowledges the doctor’s efforts and seems to accept their own mortality.
Choice C rationale
This statement indicates denial. The patient is dismissing the doctor’s prognosis and expressing disbelief about the severity of their condition.
Choice D rationale
This statement suggests anger or frustration towards the doctor, but it does not necessarily indicate denial.

A. Monitor peripheral pulses every 8 hours B. Measure urine output every 4 hours C. Maintain NPO status D. Ambulate the patient three times daily

Correct Answer is C

Explanation

Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.

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The nurse is providing care for a patient who had surgical repair of a paraesophageal (rolling) hernia. The nurse observes that the patient is having difficulty swallowing during the first postoperative meal.What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has been diagnosed with end-stage liver cancer. Which statement by the patient indicates that the patient is in the denial phase of the grief process?

Correct Answer is C

Explanation

A nurse is contributing to the care plan for a patient who has acute pancreatitis. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is providing care for an elderly patient who is experiencing constipation. What action should the nurse take?

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