Nokea
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
- A. Gallstones
- B. Hypolipidemia
- C. COPD
- D. Diabetes mellitus
Correct Answer: A
Rationale: The correct answer is A: Gallstones. Acute pancreatitis is commonly caused by gallstones or alcohol consumption. Gallstones can block the pancreatic duct, leading to inflammation. Hypolipidemia, COPD, and diabetes mellitus are not directly associated with pancreatitis. This history finding helps the nurse identify the potential cause and plan appropriate care.
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Priority Decision: Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220 mL of gastric contents. How should the nurse respond?
- A. Return the aspirate to the stomach and recheck the volume of aspirate in an hour.
- B. Return the aspirate to the stomach and continue with the tube feeding as planned.
- C. Discard the aspirate to prevent overdistending the stomach when the new feeding is given.
- D. Notify the health care provider that the feedings have been scheduled too frequently to allow for stomach emptying
Correct Answer: B
Rationale: Returning the aspirate to the stomach and continuing the feeding is standard practice as long as the volume is within safe limits.
To prevent gastroesophageal reflux in a male client with a hiatal hernia, the nurse should provide which of the following discharge instructions?
- A. "Lie down after meals to promote digestion."
- B. "Avoid coffee and alcoholic beverages."
- C. "Take antacids with meals."
- D. "Limit fluid intake with meals."
Correct Answer: B
Rationale: The correct answer is B: "Avoid coffee and alcoholic beverages." This is because both coffee and alcohol can relax the lower esophageal sphincter, leading to increased likelihood of gastroesophageal reflux.
A: "Lie down after meals" can worsen reflux symptoms as gravity helps keep stomach contents down.
C: "Take antacids with meals" may provide temporary relief but does not address the underlying cause of reflux.
D: "Limit fluid intake with meals" can help reduce bloating but has no direct impact on preventing reflux.
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.
The gallbladder contracts in response to
- A. vagal stimulation only.
- B. cholecystokinin and vagal stimulation.
- C. cholecystokinin and secretin.
- D. a low pH of chyme.
Correct Answer: B
Rationale: The gallbladder contracts in response to cholecystokinin and vagal stimulation. Cholecystokinin is released in response to the presence of fatty acids and amino acids in the duodenum, signaling the gallbladder to contract and release bile. Vagal stimulation also plays a role in gallbladder contraction by transmitting signals from the brain to the gallbladder. Secretin is primarily involved in stimulating pancreatic secretion, not gallbladder contraction. A low pH of chyme does not directly stimulate gallbladder contraction.
Which of the following is not a component of gastric juice?
- A. Pepsinogen
- B. Hydrochloric acid
- C. Bile
- D. Mucus
Correct Answer: C
Rationale: The correct answer is C: Bile. Bile is not a component of gastric juice; it is produced by the liver and stored in the gallbladder to aid in digestion in the small intestine. Pepsinogen, hydrochloric acid, and mucus are all components of gastric juice. Pepsinogen is the inactive form of pepsin, an enzyme that breaks down proteins. Hydrochloric acid helps in the digestion of food and kills bacteria. Mucus protects the stomach lining from the acidic environment.