Nokea
A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
- A. Turn the client on his left side.
- B. Sit the client upright.
- C. Prepare to add insulin to the TPN infusion.
- D. Stop the TPN infusion.
Correct Answer: D
Rationale: The correct answer is D: Stop the TPN infusion. If the TPN solution is infusing too rapidly, stopping the infusion is the most appropriate immediate action to prevent potential complications such as hyperglycemia, fluid overload, or electrolyte imbalances. This allows the nurse to assess the situation, adjust the infusion rate, and prevent harm to the client.
A: Turning the client on his left side or sitting the client upright would not directly address the issue of the TPN solution infusing too rapidly.
C: Adding insulin to the TPN infusion without assessing the client's blood glucose levels and consulting with the healthcare provider could lead to hypoglycemia and is not the initial priority when the TPN rate is too fast.
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Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
- A. A sedentary lifestyle and smoking.
- B. A history of hemorrhoids and smoking.
- C. Alcohol abuse and a history of acute renal failure.
- D. Alcohol abuse and smoking.
Correct Answer: D
Rationale: The correct answer is D: Alcohol abuse and smoking. Both alcohol abuse and smoking are well-established risk factors for peptic ulcers. Alcohol can irritate and damage the stomach lining, while smoking can increase stomach acid production and weaken the stomach lining. These factors can contribute to the development of peptic ulcers.
Choice A (A sedentary lifestyle and smoking) is incorrect because while smoking is a risk factor, a sedentary lifestyle is not directly linked to the development of peptic ulcers.
Choice B (A history of hemorrhoids and smoking) is incorrect because hemorrhoids are not a known risk factor for peptic ulcers.
Choice C (Alcohol abuse and a history of acute renal failure) is incorrect because acute renal failure is not typically associated with an increased risk of peptic ulcers, unlike alcohol abuse.
Gastric secretions:
- A. Decrease when a person thinks of food.
- B. Contain a substance which is essential for absorption of vitamin B12 from terminal ileum.
- C. Contain HCL secreted by chief cells.
- D. Are essential for fat digestion and absorption.
Correct Answer: B
Rationale: Step-by-step rationale:
1. Gastric secretions contain intrinsic factor, essential for vitamin B12 absorption from the terminal ileum.
2. Intrinsic factor binds to vitamin B12 to facilitate its absorption.
3. Without intrinsic factor, vitamin B12 absorption is impaired, leading to pernicious anemia.
4. Therefore, choice B is correct.
Summary:
- Choice A is incorrect as gastric secretions increase, not decrease, when a person thinks of food.
- Choice C is incorrect as hydrochloric acid (HCl) is secreted by parietal cells, not chief cells.
- Choice D is incorrect as fat digestion primarily occurs in the small intestine with the help of pancreatic enzymes, not gastric secretions.
This blind tube is about 9 cm long, is filled with lymph nodules and attaches to the cecum. This blind tube is called the
- A. epiploic appendix.
- B. haustra.
- C. vermiform appendix.
- D. tenia coli.
Correct Answer: C
Rationale: The correct answer is C: vermiform appendix. The vermiform appendix is a blind tube, around 9 cm long, filled with lymph nodules, and attaches to the cecum. This anatomical description matches the characteristics of the vermiform appendix. The epiploic appendix (choice A) refers to small fatty projections on the colon's surface, not a blind tube. Haustra (choice B) are the pouches along the colon's length, not a blind tube. Tenia coli (choice D) are the three bands of longitudinal muscle in the colon, not a blind tube. Therefore, the vermiform appendix is the correct answer.
The nurse is assessing a patient who had an abdominal hysterectomy. Which of the following signs of infection should the nurse be most concerned about?
- A. Redness around the incision site
- B. A temperature of 99°F
- C. Complaints of mild abdominal cramping
- D. Purulent drainage from the incision site
Correct Answer: D
Rationale: The correct answer is D: Purulent drainage from the incision site. Purulent drainage indicates an active infection, requiring immediate attention and intervention to prevent serious complications. Redness and a low-grade fever can be common in the early stages of healing and may not necessarily indicate infection. Complaints of mild cramping are also common post-surgery and may not specifically point to infection. Purulent drainage is a more specific and concerning sign of infection as it indicates the presence of pus and bacteria at the incision site, requiring prompt medical evaluation and treatment to prevent further complications.
Bile contains all of the following except:
- A. Alkaline phosphatase +
- B. K
- C. Cholesterol
- D. CCK
Correct Answer: B
Rationale: Bile does not contain potassium (K) as it is not a component of bile. The correct answer is B. Alkaline phosphatase is present in bile and aids in digestion. Cholesterol is also found in bile. CCK (Cholecystokinin) is a hormone released by the small intestine to stimulate bile release. Potassium is not a part of the composition of bile.