Nokea
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Water will deplete electrolytes resulting in metabolic acidosis.
- B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
- D. Saline will increase peristalsis in the bowel.
Correct Answer: A
Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
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Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. I would notify my physician immediately if I experience nausea, vomiting, and double vision.'
- B. I could stop taking this medication when I begin to feel better.'
- C. I should only take the medication if my heart rate is greater than 100 bpm.'
- D. I should always take this medication with an antacid.'
Correct Answer: A
Rationale: The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. 'Feeling better' indicates the drug is working and medication therapy must be continued. Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. Antacids decrease the effectiveness of digoxin.
A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a small-bore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
- A. Aspirate gastric contents
- B. Auscultate air insufflated through the tube
- C. Obtain a chest x-ray
- D. Place the tip of the tube under water and observe for air bubbles
Correct Answer: C
Rationale: A chest x-ray is the most reliable method to confirm small-bore feeding tube placement, as other methods may be inconclusive or unreliable.
Which task should be delegated to the licensed practical nurse?
- A. Administering heparin subcutaneously
- B. Feeding the client with a percutaneous endoscopy gastrostomy tube
- C. Removing a peripherally inserted central line
- D. Monitoring chest tube drainage
- E. Performing tracheostomy care
Correct Answer: A, B, D, E
Rationale: LPNs can administer subcutaneous heparin (A), feed via PEG tube (B), monitor chest tubes (D), and perform tracheostomy care (E). Removing a PICC line (C) requires RN-level expertise due to potential complications.
The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?
- A. Steamed broccoli
- B. Wheat toast
- C. Chocolate chip cookie
- D. Bran cereal
Correct Answer: A
Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (B), chocolate chip cookies (C), and bran cereal (D) contain gluten.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.