The nurse has performed nasogastric decompression for a client who has undergone colostomy surgery. Which of the following related interventions should a nurse consider for this client?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Measure the amount of fluids lost. Rationale: After colostomy surgery, nasogastric decompression is often performed to alleviate gastrointestinal distention and prevent complications like vomiting and aspiration. Monitoring the amount of fluids lost through nasogastric decompression is crucial as it helps assess the client's fluid balance and overall status. This measurement guides the healthcare team in determining the client's hydration status and adjusting fluid replacement therapy accordingly. Option A) Inspect the swelling of joints is incorrect as it is not directly related to nasogastric decompression after colostomy surgery. Joint swelling may be indicative of other conditions but is not a priority in this case. Option B) Inspect the bleeding wound is also incorrect as it does not pertain to nasogastric decompression. While wound care is essential post-colostomy surgery, it is not specifically related to nasogastric decompression monitoring. Option C) Monitor pulse pressure and rate is not directly linked to nasogastric decompression. While monitoring vital signs is crucial in client care, assessing the amount of fluids lost through the nasogastric tube takes precedence in this situation. Educational Context: Understanding the rationale behind monitoring fluid loss post-colostomy surgery is crucial for nursing practice. It ensures that nurses can provide safe and effective care to clients undergoing such procedures. By emphasizing the importance of monitoring fluid balance, nurses can prevent complications and promote positive client outcomes. This educational rationale highlights the significance of prioritizing specific interventions based on the client's condition and the prescribed treatment.

Correct Answer: B

Rationale: In the context of NCLEX questions on gastrointestinal disorders, the priority decision regarding the use of medications for obesity is crucial for safe and effective patient care. Option B, stating that over-the-counter (OTC) diet aids are safer than other agents and can be useful in controlling appetite, is the correct answer. This is because OTC diet aids are generally considered safer due to their lower potency and fewer side effects compared to prescription weight loss medications. Option C is incorrect because while it is true that drugs should be used as adjuncts to diet and exercise for obesity treatment, it does not specifically address the safety or efficacy of OTC diet aids. Option D is incorrect as it generalizes all weight control drugs as capable of altering CNS function, which is not universally true for all medications used in obesity treatment. In an educational context, it is important for nurses to understand the differences between various weight loss medications, including OTC options, prescription drugs, and their mechanisms of action, side effects, and appropriate patient education. Nurses should also be able to prioritize patient safety and provide evidence-based information to guide patients in making informed decisions about weight loss interventions.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Report any bloody drainage from the NG tube. This is the priority action because post-esophagogastrostomy, the patient is at risk for complications such as hemorrhage, infection, or anastomotic leak. Bloody drainage can be indicative of a serious issue like hemorrhage, which requires immediate intervention to prevent further complications or deterioration. Option A is too vague and does not provide specific guidance on what action to take. Option C, maintaining the patient in semi-Fowler's or Fowler's position, is important for patient comfort and to prevent reflux but is not the priority over monitoring for potential complications. Option D, monitoring for abdominal distention, is relevant but not as critical as detecting bleeding, which can be life-threatening. Educationally, this question highlights the importance of prioritizing nursing actions based on the patient's condition post-surgery. It emphasizes the significance of recognizing and responding promptly to signs of complications to ensure optimal patient outcomes and safety. Nurses must be vigilant in assessing and reporting any abnormal findings to the healthcare team promptly.

Correct Answer: C

Rationale: The correct answer is C) Wear gloves and wash hands with soap and water. When caring for a patient with Clostridium difficile (C. diff), the most crucial aspect is to prevent the spread of the infection. C. diff is highly contagious and can be transmitted through spores that are resistant to many disinfectants. Wearing gloves and practicing proper hand hygiene with soap and water are essential to prevent the spread of the infection to other patients, healthcare workers, and the environment. Option A is incorrect because cleaning the entire room with ammonia is not the priority when caring for a patient with C. diff. While environmental cleaning is important, the immediate focus should be on preventing transmission through proper hand hygiene. Option B is incorrect because while probiotics may be beneficial in some cases to restore gut flora balance, it is not the priority when dealing with a C. diff infection. Option D is incorrect because alcohol-based hand sanitizers are not effective against C. diff spores. Washing hands with soap and water is necessary to mechanically remove the spores from the hands. In an educational context, it is crucial for nurses to understand the principles of infection control when caring for patients with infectious diseases like C. diff. Emphasizing the importance of proper hand hygiene, wearing appropriate personal protective equipment, and following standard precautions can help prevent the spread of infections in healthcare settings.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Upper small intestine. Intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration are classic signs of a gastrointestinal (GI) obstruction. The upper small intestine (duodenum and jejunum) is the most common site for mechanical obstructions due to its narrower luminal diameter and more fixed position in the abdomen. The incorrect options are: A) Large intestine: Symptoms of a large intestine obstruction typically include changes in bowel habits, such as constipation or diarrhea, and abdominal distention. B) Esophageal sphincter: An issue with the esophageal sphincter would present with dysphagia, heartburn, regurgitation, and chest pain. D) Lower small intestine: Obstructions in the lower small intestine (ileum) would manifest with symptoms like abdominal distention, cramping, and constipation. Educational context: Understanding the location-specific manifestations of GI disorders is crucial for nurses in assessing and managing patients with potential obstructions. Knowing the typical signs and symptoms associated with different areas of the bowel helps guide clinical decision-making, including appropriate diagnostic tests and treatment interventions. This knowledge is essential for nurses preparing for the NCLEX exam and for providing safe and effective patient care in clinical practice.