Nokea
A client has diarrhea due to a high carbohydrate and electrolyte content of the fluid in the tube feeding. Which of the following nursing actions will be most appropriate?
- A. Instructing the client to remain in a semi-Fowler's position
- B. Consulting the physician about decreasing the infusion rate
- C. Administering the tube feedings continuously
- D. Maintaining the tube patency
Correct Answer: B
Rationale: Reducing the infusion rate allows better absorption of nutrients and decreases the risk of osmotic diarrhea.
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Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?
- A. Loud gurgles
- B. High-pitched gurgles
- C. Absent bowel sounds
- D. Frequent clicking sounds
Correct Answer: C
Rationale: The correct answer is C, absent bowel sounds. Absence of bowel sounds may indicate a serious issue requiring further assessment. Normal bowel sounds include soft gurgles and clicks, so choices A, B, and D are variations of normal findings and do not necessarily indicate a need for further assessment. Absent bowel sounds could indicate bowel obstruction, peritonitis, or ischemia, warranting a focused abdominal assessment to determine the underlying cause.
Which of these is most associated with villi?
- A. haustra
- B. lacteals
- C. bacterial flora
- D. intestinal glands
Correct Answer: B
Rationale: The correct answer is B: lacteals. Villi are small finger-like projections in the small intestine that increase surface area for nutrient absorption. Lacteals are lymphatic vessels found in villi responsible for absorbing dietary fats. Haustra are pouches in the colon, not associated with villi. Bacterial flora is mainly found in the large intestine, not specifically associated with villi. Intestinal glands are responsible for producing digestive enzymes, but they are not directly associated with villi.
The projection from the posterior edge of the soft palate elevates and helps close off the nasopharynx when swallowing. The projection is called the
- A. buccal fat pad.
- B. epiglottis.
- C. uvula.
- D. palatine tonsil.
Correct Answer: C
Rationale: The correct answer is C: uvula. The uvula is a teardrop-shaped projection from the posterior edge of the soft palate that elevates during swallowing to help close off the nasopharynx, preventing food or liquids from entering the nasal cavity. The uvula's contraction is essential for proper swallowing function.
A: Buccal fat pad - located in the cheek area, not involved in swallowing or closing off the nasopharynx.
B: Epiglottis - a flap of tissue that covers the trachea during swallowing to prevent food from entering the airway, not related to closing off the nasopharynx.
D: Palatine tonsil - located on the sides of the throat, important for immune function but not directly involved in swallowing or closing off the nasopharynx.
The processes of chewing are referred to as _____.
- A. churning
- B. mastication
- C. peristalsis
- D. deglutition
Correct Answer: B
Rationale: The correct answer is B: mastication. Mastication refers to the mechanical process of chewing food in the mouth using the teeth and jaws. This process breaks down food into smaller pieces, making it easier to swallow and digest. Churning (A) is the mixing of food with digestive enzymes in the stomach. Peristalsis (C) is the involuntary muscle contractions that move food through the digestive tract. Deglutition (D) is the process of swallowing food. Mastication is the most appropriate term for the process of chewing specifically.
The tunica muscularis in the superior esophagus is made up of ______ muscle.
- A. skeletal
- B. cardiac
- C. smooth
- D. smooth and skeletal
Correct Answer: A
Rationale: The correct answer is A: skeletal muscle. The superior esophagus contains skeletal muscle in its tunica muscularis, allowing for voluntary control over swallowing. Cardiac muscle is found in the heart, not in the esophagus. Smooth muscle is present in the lower esophagus for involuntary movements. Choice D is incorrect as the superior esophagus does not contain a mix of smooth and skeletal muscle.