Nokea
A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
- A. Increase ambulation.
- B. Decrease fluid intake.
- C. Increase protein intake.
- D. Offer the client the bedpan every 2 hr.
Correct Answer: A
Rationale: The correct answer is A: Increase ambulation. Ambulation helps stimulate peristalsis by promoting movement in the gastrointestinal tract. This movement aids in preventing or alleviating paralytic ileus, a common postoperative complication. Increasing ambulation helps to increase muscle tone and activity in the intestines, promoting bowel motility.
Summary of other choices:
B: Decrease fluid intake - This is incorrect because adequate hydration is essential for promoting peristalsis and preventing constipation.
C: Increase protein intake - Protein intake is important for wound healing and overall nutrition but does not directly impact peristalsis.
D: Offer the client the bedpan every 2 hr - While providing opportunities for toileting is important, it does not directly promote peristalsis like ambulation does.
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A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning
- A. , what should the nurse plan to assess more frequently than is routine?
- B. Apical pulse
- C. Bowel sounds
- D. Breath sounds
Correct Answer: D
Rationale: The correct answer is D: Breath sounds. In an unconscious stroke patient, airway patency and adequate oxygenation are critical. Assessing breath sounds more frequently than routine helps monitor for respiratory distress, such as aspiration or pneumonia. Apical pulse (B) may be important but not as immediately life-threatening as respiratory status. Bowel sounds (C) may indicate bowel function but are not as urgent as assessing breathing. By prioritizing breath sounds, the nurse can ensure timely intervention in case of respiratory compromise.
A sudden decrease in blood volume would be met by increases in epinephrine, antidiuretic hormone (vasopressin) and angiotensin II. What EFFECT would the increase in these three hormones ALL HAVE IN COMMON?
- A. increased heart rate
- B. increased fluid retention and blood volume
- C. increased PNS activity
- D. vasoconstriction and increased total peripheral resistance
Correct Answer: D
Rationale: The correct answer is D: vasoconstriction and increased total peripheral resistance. Epinephrine, antidiuretic hormone, and angiotensin II all act to increase vasoconstriction, leading to an increase in total peripheral resistance. This response is crucial during a sudden decrease in blood volume to maintain blood pressure and ensure adequate perfusion to vital organs.
Choice A (increased heart rate) is not correct because while epinephrine can increase heart rate, antidiuretic hormone and angiotensin II do not directly affect heart rate.
Choice B (increased fluid retention and blood volume) is not correct because antidiuretic hormone and angiotensin II can increase fluid retention, but epinephrine does not have this effect.
Choice C (increased PNS activity) is not correct because these hormones actually stimulate the sympathetic nervous system (SNS) leading to vasoconstriction and increased blood pressure, not the parasympath
The optimum pH for trypsin and chymotrypsin is about
- A. 1-3.
- B. 5-7.
- C. 7-9.
- D. 10-12.
Correct Answer: C
Rationale: The correct answer is C (7-9) because trypsin and chymotrypsin are proteolytic enzymes that function optimally in slightly basic environments. At pH 7-9, these enzymes maintain their structural integrity and catalytic activity. Choices A, B, and D are incorrect because trypsin and chymotrypsin are not acidic enzymes, so pH ranges 1-3 and 10-12 would denature and inactivate them, while pH 5-7 is still on the acidic side, not optimal for these enzymes.
Which esophageal disorder is described as a precancerous lesion associated with GERD?
- A. Achalasia
- B. Barrett's esophagus
- C. Esophageal strictures
- D. Esophageal diverticula
Correct Answer: B
Rationale: Barrett's esophagus is the correct answer because it is a precancerous condition resulting from long-term GERD. The constant exposure to stomach acid causes changes in the esophageal lining, increasing the risk of esophageal cancer.
Achalasia (A) is a motility disorder characterized by difficulty swallowing due to impaired esophageal muscle movement. Esophageal strictures (C) are narrowing of the esophagus, commonly caused by chronic inflammation or scarring, but not directly associated with GERD. Esophageal diverticula (D) are outpouchings in the esophageal wall, not specifically linked to GERD or cancer risk.
When monitoring the food intake of a client with Crohn's disease, the nurse observes that the client does not eat most of the food serve The nurse learns that the client finds the food unappetizing. Which of the following steps should the nurse take to address this issue?
- A. Explain to the client the benefits of eating the prescribed food
- B. Request the dietitian to suggest more acceptable food
- C. Provide the client total parenteral nutrition and lipid infusions
- D. Provide the client elemental diet formula and 5-ASA medications
Correct Answer: B
Rationale: The correct answer is B. Request the dietitian to suggest more acceptable food. This step is appropriate because it involves seeking help from a professional who can provide tailored dietary recommendations based on the client's preferences and restrictions. The dietitian can work with the client to identify foods that are both appetizing and suitable for managing Crohn's disease.
Explanation for why the other choices are incorrect:
A: Explaining the benefits of eating the prescribed food may not address the client's issue of finding the food unappetizing.
C: Providing total parenteral nutrition and lipid infusions is an extreme measure and should only be considered when all other options have been exhausted.
D: Providing elemental diet formula and 5-ASA medications may not address the client's immediate concern of finding the food unappetizing.