EVOLVE MED SURG HESI (With 100% correct answers)

The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.) A. Frequent oral care every 2 hours while awake. B. Use incentive spirometer every 2 hours. C. Empty contents from NG tube every 8 hours. D. Ambulate within 1 hour of return from the PACU. E. Limit visitors until postoperative day 2. correct answers Correct Answer: A,B,C Rationale:One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery. The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? A.Around the waist B.At the inner aspect of the left stump C.At the outer aspect of the left stump D.At the left groin area correct answers Correct Answer: A Rationale:The waist is the anchor point for the bandage for an above the knee amputation. A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legs correct answers Correct Answer: B Rationale:Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the center of gravity in the older adult. Although the arms comprise a part of the upper torso, they do not reflect the best and most complete answer. A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify the dose. correct answers Correct Answer: A