Nokea
A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene?
- A. Checking tube placement every 4 or 8 hours
- B. Monitoring and client listening drainage from the NG tube
- C. Pinning the tube to the gown so the client cannot turn the head
- D. Providing oral care every 4 to 8 hours
Correct Answer: C
Rationale: Pinning the NG tube to restrict head movement is incorrect, as it can cause discomfort or dislodge the tube. The client should have freedom to move their head. The other actions are appropriate for NG tube care.
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A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first?
- A. Notify the surgeon.
- B. Put on a pair of gloves.
- C. Reinsert the NG reinsert the NG tube.
- D. Take a set of vital signs.
Correct Answer: B
Rationale: Standard precautions require putting on gloves first to protect the nurse from exposure to blood and body fluids. This is the priority before assessing vital signs, notifying the surgeon, or attempting to reinsert the NG tube.
A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.)
- A. Chocolate
- B. Decaffeinated coffee
- C. Citrus fruits
- D. Peppermint
- E. Tomato sauce
Correct Answer: A,C,D,E
Rationale: Chocolate, citrus fruits, peppermint, and tomato-based products exacerbate GERD by promoting reflux. Decaffeinated coffee is less likely to trigger symptoms compared to caffeinated beverages.
After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best?
- A. Bacteria can often cause ulcers.
- B. This operation often causes ulcers.
- C. The medication keeps your blood pH.
- D. It prevents stress-related ulcers.
Correct Answer: D
Rationale: Pantoprazole is given post-surgery to prevent stress-related ulcers, which can occur due to surgical stress, not because of bacteria, the operation itself, or blood pH regulation.
A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority?
- A. Assess the client's oxygenation.
- B. Facilitate a STAT chest x-ray.
- C. Prepare for immediate surgery.
- D. Start two large-bore IVs.
Correct Answer: A
Rationale: Subcutaneous emphysema suggests possible airway or esophageal injury. The priority is ensuring airway and breathing (assessing oxygenation) before diagnostic or therapeutic interventions, following the ABC (airway, breathing, circulation) priority framework.
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.)
- A. Delayed gastric emptying
- B. Eating large meals
- C. Hiatal hernia
- D. Obesity
- E. Viral infections
Correct Answer: A,B,C,D
Rationale: Delayed gastric emptying, large meals, hiatal hernia, and obesity are known risk factors for GERD. Viral infections are not associated with GERD, though Helicobacter pylori infection is.