The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
Promote effective swallowing.
Maintain intact oral mucosa.
Prevent esophageal reflux.
Increase intestinal peristalsis.
The Correct Answer is C
Choice A rationale
Promoting effective swallowing is important for patients with dysphagia, but it is not the primary goal for a client with a sliding hiatal hernia. The main concern with a sliding hiatal hernia is the prevention of gastroesophageal reflux, which can lead to complications such as esophagitis and Barrett’s esophagus.
Choice B rationale
Maintaining intact oral mucosa is crucial for patients with conditions affecting the mouth, such as oral mucositis or infections. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
Choice C rationale
Preventing esophageal reflux is the primary goal for a client with a sliding hiatal hernia. This condition occurs when the stomach slides up into the chest through the diaphragm, leading to gastroesophageal reflux disease (GERD). Nursing actions should aim to reduce reflux symptoms by advising the client to eat smaller meals, avoid lying down after eating, and elevate the head of the bed.
Choice D rationale
Increasing intestinal peristalsis is important for patients with conditions like constipation or ileus. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.
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Correct Answer is C
Explanation
Choice A rationale
Auscultating bowel sounds is important for assessing gastrointestinal function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice B rationale
Measuring oxygen saturation is important for assessing respiratory function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice C rationale
Checking serum creatinine is crucial before administering vancomycin because this medication can be nephrotoxic. Monitoring kidney function helps prevent potential renal damage.
Choice D rationale
Assessing body temperature is important for monitoring infection, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Correct Answer is D
Explanation
Choice A rationale
Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.
Choice B rationale
Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.
Choice C rationale
Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.
Choice D rationale
Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.