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A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting?
- A. Intermittent suction at 70 mmHg
- B. Intermittent suction at 100 mmHg
- C. Continuous suction at 100 mmHg
- D. Continuous suction at 70 mmHg
Correct Answer: A
Rationale: Intermittent suction at 70 mmHg (A) is appropriate for gastric decompression in bowel obstruction to prevent mucosal damage while effectively removing gastric contents.
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The nurse is taking care of a client that is scheduled to undergo a gastric analysis at 8:00 AM tomorrow. Which should be included in the client's plan of care?
- A. Instruct the client that she should not eat or drink anything after midnight.
- B. Teach the client that in case she feels hungry, she can chew some gum.
- C. Instruct the client that she needs to be on bed rest for 2 hours after the procedure.
- D. Tell the client that she is allowed to smoke 1 hour prior to surgery.
Correct Answer: A
Rationale: Fasting after midnight (A) ensures accurate gastric analysis results. Chewing gum (B), bed rest (C), and smoking (D) are not appropriate.
The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
The nurse is caring for a client admitted with an exacerbation of Crohn's disease
Item 1 of 1
• History and Physical
A 25-year-old male has had Crohn's disease for over six years. He is admitted to the hospital for severe diarrhea, abdominal pain, and fatigue. The client will be admitted for fluid replacement, antibiotics, steroids, and pain control.
• Physician Orders
• Admit to the medical-surgical unit
• Nothing by mouth (NPO)
• Gastroenterology consultation
• Lactated Ringers at 80 mL/hr
• Metronidazole 500 mg intravenous piggyback q 8 hours
• Methylprednisolone 125 mg intravenously q 12 hours
Drag the words from the word choices below to fill in each blank of the following sentences: The prescribed------------------------------puts the client at risk for complications such as hyperglycemia. To recognize this complication the nurse should monitor the client’s------------------
- A. metronidazole
- B. lactated ringers
- C. methylprednisolone
- D. nothing by mouth status
- E. capillary blood glucose
- F. hemoglobin A1C
Correct Answer: C,E
Rationale: Methylprednisolone is a corticosteroid that may cause elevated blood glucose and even hyperglycemia (blood glucose 250 mg/dL or greater). This is a common treatment for exacerbations of inflammatory bowel disorders. Hyperglycemia may complicate outcomes by delaying wound healing and increasing the client’s risk for infection. Thus, the nurse should monitor the capillary blood glucose and collaborate with the primary healthcare provider.
Monitoring the hemoglobin A1C is useful for monitoring the clinical progress of a client with chronic diabetes. This value is collected every 90-120 days and would not be useful during this acute course of steroids.
During an exacerbation of Crohn’s disease, it is likely that the client will be prescribed antibiotics such as metronidazole. The client will also have fluid repletion, and isotonic solutions such as lactated ringers may be given to rehydrate the client.
The nurse is caring for a client in the intensive care unit (ICU) being mechanically ventilated via an endotracheal tube (ETT) for head trauma following a motor vehicle crash (MVC). The primary healthcare provider (PHCP) prescribes famotidine 20 mg intravenous (IV) push. The nurse understands that this medication is intended to
- A. Decrease any gagging by the ETT
- B. Prevent the formation of stress ulcers
- C. Provide sedation
- D. Increase gastric motility
Correct Answer: B
Rationale: Famotidine, an H2 blocker, is used in ICU settings to prevent stress ulcers by reducing gastric acid. It does not affect gagging, provide sedation, or increase motility.
The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?
- A. Administer analgesics to control pain
- B. Monitor for signs of infection
- C. Monitor for signs of hypovolemia
- D. Ensure that the ascitic fluid is sent to the lab for analysis
Correct Answer: C
Rationale: Monitoring for hypovolemia (C) is critical after paracentesis due to the risk of fluid shifts from removing large volumes of ascitic fluid.