Nokea
A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Irrigate the NG tube.
- B. Performing frequent oral care.
- C. Re-positioning the tube every 4 hours.
- D. Taking and recording vital signs.
Correct Answer: B
Rationale: Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Irrigating the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.
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A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.)
- A. Anorexia
- B. Dyspepsia
- C. Intolerance of fatty foods
- D. Pernicious anemia
- E. Nausea and vomiting
Correct Answer: C,D
Rationale: Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On physician and the client is substance and rapid. What action takes priority?
- A. Administer the prescribed pain medication.
- B. Notify the health care provider immediately.
- C. Prepare all four abdominal quadrants.
- D. Take and document a set of vital signs.
Correct Answer: B
Rationale: This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not persens the abdomen or give pain medication since the client may need to sign consent for surgery.
A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to provide better nutrition? (Select all that apply.)
- A. Administer vitamin B12 injections.
- B. Ask the provider about folic acid replacement.
- C. Request a digestive enzyme supplement.
- D. Obtain consent for total parenteral nutrition.
- E. Provide iron supplements for the client.
Correct Answer: A,B,E
Rationale: After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, and iron deficiency. The nurse should administer vitamin B12 injections, ask about folic acid replacement, and provide iron supplements. The client does not need enteral feeding or total parenteral nutrition.
A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best?
- A. Ask your provider about it first.
- B. Slippery elm has no benefit for this problem.
- C. Slippery elm is often used for this disorder.
- D. There is no evidence that this will work.
Correct Answer: B
Rationale: Slippery elm is not recognized as an effective treatment for peptic ulcer disease. There is no evidence supporting its use for this condition, and it is not commonly recommended.
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate?
- A. Assess the client for iodine or shellfish allergies.
- B. Educate the client on the side effects of sedation.
- C. Inform the client a second scan may be needed.
- D. Teach the client about bowel preparation for the scan.
Correct Answer: C
Rationale: A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.