Nokea
A nurse is caring for a patient who had abdominal surgery and has a nasogastric tube attached to low suction. Which nursing actions are appropriate when caring for this patient? Select all that apply.
- A. Irrigating the tube with 30-mL normal saline solution
- B. Confirming tube placement via pH testing of gastric secretions
- C. Positioning the air vent at the level of the patient's umbilicus
- D. Instilling irrigation via the blue air vent
- E. Monitoring the patient's abdomen for distention
- F. Documenting the nasogastric irrigation and drainage with I & O
Correct Answer: A,B,E,F
Rationale: Appropriate actions include irrigating with saline (A), confirming placement via pH (B), monitoring for distention (E), and documenting I&O (F). The air vent should be above the stomach, not at the umbilicus (C), and irrigation goes through the main lumen, not the air vent (D).
You may also like to solve these questions
A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse they are feeling dizzy and nauseated and then vomits. What should be the nurse's next action?
- A. Reassuring the patient that this is a normal reaction to the procedure
- B. Stopping the procedure, preparing to administer CPR, and notifying the primary care provider
- C. Stopping the procedure, assessing vital signs, and notifying the health care provider
- D. Pausing the procedure, waiting 5 minutes, and then resuming the procedure
Correct Answer: C
Rationale: Dizziness, nausea, and vomiting suggest vagal stimulation. Stopping the procedure, assessing vital signs, and notifying the provider (C) is appropriate. Reassuring (A) ignores the risk, CPR (B) is premature, and resuming after 5 minutes (D) is unsafe without assessment.
For a patient with which health problem or issue would a nurse expect the health care provider to order colostomy irrigation?
- A. IBS
- B. Left-sided end colostomy in the sigmoid colon
- C. Postradiation damage to the bowel
- D. Crohn disease
Correct Answer: B
Rationale: Colostomy irrigation is indicated for left-sided end colostomies in the sigmoid colon (B) to promote regular evacuation. IBS (A), postradiation damage (C), and Crohn disease (D) are contraindications due to bowel instability.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
- A. Having the patient consume a low-fiber diet several days before the test
- B. Having the patient take bisacodyl and ingest a gallon oral polyethylene glycol solution (PEG)
- C. Preparing the patient for the use of general anesthesia during the test
- D. Explaining that barium contrast mixture will be given to drink before the test
Correct Answer: A
Rationale: A low-fiber diet several days before a colonoscopy (A) reduces residue in the colon. PEG is used, but bisacodyl (B) isn't standard for all preps. Conscious sedation, not general anesthesia (C), is typical, and barium (D) is for other GI tests.
A community health nurse is providing an adult education session about colon cancer. Which signs and symptoms of this cancer will the nurse include? Select all that apply.
- A. Blood in the stool
- B. Previous colonoscopy
- C. Passing two large bowel movements daily
- D. Unintentional weight loss
- E. Upper abdominal cramping
- F. Previous opioid use
Correct Answer: A,D
Rationale: Colon cancer symptoms include blood in the stool (A) and unintentional weight loss (D). Previous colonoscopy (B) and opioid use (F) are not symptoms, two large bowel movements (C) are normal, and upper abdominal cramping (E) is less specific.
A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse's first action in this situation?
- A. Reassuring the patient that this is a normal with a new ostomy
- B. Notifying the health care provider that the stoma is prolapsed
- C. Having the patient rest for 30 minutes to see if the prolapse resolves
- D. Replacing the appliance with a larger appliance
Correct Answer: C
Rationale: A protruding stoma suggests prolapse; the first action is having the patient rest for 30 minutes (C) to see if it resolves. Reassuring (A) is incorrect as prolapse isn't normal, notifying the provider (B) is premature, and a larger appliance (D) doesn't address the issue.