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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.
Choice B rationale
Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.
Choice C rationale
Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.
Choice D rationale
Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.
Correct Answer is A
Explanation
Choice A rationale
Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.
Choice B rationale
Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice C rationale
Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice D rationale
Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.