A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The
... [Show More] preceptor should intervene when the graduate nurse performs which interventions? Select all that apply.
1. Checks for residual every 4 hours
2. Places client in semi-Fowler's position
3. Plugs the air vent if gastric content refluxes
4. Provides mouth care every 4 hours
5. Turns off suction when auscultating bowel sounds - answer1,3
The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel?
1. Absent bowel sounds
2. Borborygmi sounds
3. High-pitched and gurgling sounds
4. Swishing or buzzing sounds - answer1
A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply.
1. "No food or drink is allowed 8 hours prior to the test."
2. "Prophylactic antibiotics are taken as prescribed."
3. "Smoking must be avoided after midnight."
4. "The day prior to the procedure your diet will be clear liquids."
5. "You will drink polyethylene glycol as directed the day before." - answer1,4,5
When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.
1. Flank pain radiating to the groin
2. High-protein food ingestion before the onset of pain
3. Low-grade fever with chills
4. Pain at the umbilicus
5. Right upper-quadrant (RUQ) pain radiating to the right shoulder - answer3,5
The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse?
1. Abdominal cramping
2. Frequent, watery stools
3. Positive rebound tenderness
4. Recurring flatus - answer3
The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply.
1. Elevate the head of the hospital bed
2. Instruct the client to avoid tobacco and caffeine [Show Less]