Your goal is to minimize David's risk of complications after a heriorrhaphy. You instruct the patient to:

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Splint the incision if he can't avoid sneezing or coughing. This instruction is crucial after a herniorrhaphy (surgical repair of a hernia) to minimize the risk of complications. By splinting the incision during sneezing or coughing, David can prevent excessive strain on the surgical site, reducing the chances of wound dehiscence or hernia recurrence. Option A, which suggests avoiding pain medication, is incorrect because adequate pain management is essential postoperatively to promote patient comfort and mobility, ultimately improving outcomes. Pain control also helps prevent complications such as atelectasis due to shallow breathing. Option B, coughing and deep breathing Q2H, is incorrect immediately after a herniorrhaphy as it can increase intra-abdominal pressure and strain on the incision, potentially leading to complications like wound dehiscence or hernia recurrence. Option D, applying heat to scrotal swelling, is unrelated to the patient's risk of complications post-herniorrhaphy and does not address the specific care needed to minimize complications following this surgical procedure. Educationally, this rationale emphasizes the importance of proper postoperative care after a herniorrhaphy to prevent complications and promote optimal healing. By understanding the rationale behind each option, students can grasp the significance of specific nursing interventions in the context of surgical procedures, enhancing their clinical decision-making skills.

Correct Answer: B

Rationale: The correct answer is B) You'll need to lie on your right side after the test. Rationale: This instruction is crucial post liver biopsy as lying on the right side helps to apply pressure to the biopsy site, preventing bleeding or complications. Placing pressure on the site promotes hemostasis and reduces the risk of bleeding. This position also helps in detecting any signs of bleeding early on. Option A) You'll need to lie on your stomach during the test is incorrect because the patient typically lies on their back during a liver biopsy procedure. Option C) During the biopsy you'll be asked to exhale deeply and hold it is incorrect as patients are usually asked to hold their breath briefly to minimize movement during the biopsy, not exhale deeply. Option D) The biopsy is performed under general anesthesia is incorrect as liver biopsies are often performed under local anesthesia with sedation, not general anesthesia, to minimize risks associated with general anesthesia and to allow the patient to cooperate during the procedure. Educational Context: Understanding the correct positioning after a liver biopsy is essential for nursing students to provide safe and effective care to patients undergoing this procedure. Teaching patients the importance of lying on their right side post-biopsy can help prevent complications and promote optimal recovery.

Correct Answer: A

Rationale: In this scenario, option A (Dyspnea and reduced or absent breath sounds over the right lung) is the correct answer indicating a possible pneumothorax following a liver biopsy in a 62-year-old patient like Stephen. A pneumothorax occurs when air enters the pleural space, leading to lung collapse. Dyspnea and reduced breath sounds on the affected side are classic signs of a pneumothorax. Option B (Tachycardia, hypotension, and cool, clammy skin) is more indicative of shock, which could result from bleeding or other complications but is not specific to a pneumothorax. Option C (Fever, rebound tenderness, and abdominal rigidity) suggests intra-abdominal issues like peritonitis, which are not directly related to a pneumothorax. Option D (Redness, warmth, and drainage at the biopsy site) may indicate infection at the biopsy site but does not point towards a pneumothorax. Educationally, understanding the signs and symptoms of potential complications post liver biopsy is crucial for nurses caring for these patients. Recognizing the specific signs of a pneumothorax is essential for prompt intervention and preventing further complications in patients like Stephen.

Correct Answer: A

Rationale: The correct answer is A) It empties the stomach of fluids and gas. In acute pancreatitis, the gastrointestinal system needs rest to reduce pancreatic enzyme secretion. Inserting an NG tube helps decompress the stomach, reducing the stimulation of pancreatic secretions. It also prevents vomiting, which can further aggravate pancreatic inflammation. Option B) is incorrect as the NG tube does not affect the sphincter of Oddi; its primary role is in gastric decompression. Option C) is incorrect because preventing air formation in the small and large intestines is not the primary purpose of an NG tube. Option D) is incorrect as the NG tube does not remove bile from the gallbladder; its main function is to drain stomach contents. In an educational context, understanding the rationale behind interventions in acute pancreatitis is crucial for nursing practice. This scenario highlights the importance of providing accurate explanations to patients before procedures to ensure informed consent and promote patient understanding and cooperation. It also emphasizes the significance of proper patient education in managing acute gastrointestinal conditions effectively.

Correct Answer: A

Rationale: In this scenario, the correct immediate action after inserting an NG tube for liquid enteral feedings is to option A) aspirate for gastric secretions with a syringe. This is crucial to confirm correct placement of the tube in the stomach to avoid potential complications such as aspiration pneumonia if the tube is inadvertently placed in the lungs. Aspiration also helps ensure that the tube is not in the esophagus or incorrectly positioned in the stomach. Option B) beginning feeding slowly to prevent cramping is incorrect as it overlooks the essential step of verifying tube placement through gastric aspiration first. Option C) getting an X-ray of the tube within 24 hours is important for long-term monitoring but is not the immediate priority. Option D) clamping off the tube until feedings begin is incorrect as it does not address the need to confirm tube placement. Educationally, it is vital for nursing students to understand the proper sequence of actions when managing NG tubes to ensure patient safety. Emphasizing the significance of verifying tube placement through aspiration can prevent serious complications and promote optimal patient outcomes. Understanding the rationale behind each step is essential for providing safe and effective care to patients requiring enteral feedings.