Nokea
A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct Answer: B
Rationale: The correct answer is B: Oil-soluble lubricant. The rationale is that oil-based lubricants should not be used for nasogastric tube insertion due to the risk of aspiration pneumonia. The other options are appropriate for the procedure: A) Tape is used to secure the tube, C) Water with a straw is used to check tube placement, and D) A syringe is used for verification of tube placement and administration of medications. Therefore, selecting B indicates a lack of understanding of proper supplies for nasogastric tube insertion.
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The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
- A. Discarded properly and recorded as output on the client's intake and output record.
- B. Poured into the nasogastric tube through a syringe with the plunger removed.
- C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
- D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.
Correct Answer: B
Rationale: The correct answer is B because pouring the 40 mL of gastric aspirate back into the nasogastric tube through a syringe with the plunger removed ensures the undigested formula is returned to the stomach for digestion. This method maintains the balance of electrolytes and nutrients and prevents potential complications.
Choice A is incorrect because discarding the aspirate without returning it to the stomach can lead to electrolyte imbalances and nutritional deficiencies.
Choice C is incorrect because mixing the aspirate with formula before administering it can cause inaccurate dosing and potential nutrient interactions.
Choice D is incorrect because diluting the aspirate with water and forcibly injecting it back into the stomach can cause discomfort and potential complications for the client.
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
- A. To perform Valsalva's maneuver
- B. To take hold and hold a deep breath
- C. To exhale
- D. To inhale and exhale quickly
Correct Answer: B
Rationale: The correct answer is B: To take hold and hold a deep breath. This is because holding a deep breath helps prevent the aspiration of gastric contents when removing the nasogastric tube. By taking a deep breath and holding it, the client creates positive pressure in the lungs, which can help prevent the contents from entering the airway.
Rationale for other choices:
A: Performing Valsalva's maneuver (straining while holding breath) can increase intra-abdominal pressure and potentially push gastric contents upward, increasing the risk of aspiration.
C: Exhaling does not provide the same protection against aspiration as holding a deep breath.
D: Inhaling and exhaling quickly does not create the same protective mechanism as holding a deep breath.
Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?
- A. Chewing gum.
- B. Smoking cigarettes.
- C. Eating chocolate.
- D. Taking acetaminophen (Tylenol).
Correct Answer: B
Rationale: The correct answer is B: Smoking cigarettes. Smoking can increase stomach acid production and decrease blood flow to the stomach lining, which can worsen peptic ulcers. Chewing gum can actually help by increasing saliva production, which can neutralize stomach acid. Eating chocolate and taking acetaminophen are generally safe for peptic ulcer patients as long as they do not have specific allergies or sensitivities.
The nurse provides discharge instructions to a patient with hepatitis B. Which of the following statements, if made by the patient, would indicate the need for further instruction?
- A. I can never donate blood.
- B. I can never have unprotected sex.
- C. I cannot share needles.
- D. I should avoid drugs and alcohol.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): The patient should avoid drugs and alcohol to prevent further damage to the liver affected by hepatitis B. Substance abuse can exacerbate liver disease. This statement indicates understanding of the importance of liver health.
Summary of Other Choices:
A: This statement is correct because individuals with hepatitis B should not donate blood to prevent transmission.
B: This statement is correct because unprotected sex can transmit hepatitis B to sexual partners.
C: This statement is correct because sharing needles can spread hepatitis B through blood-to-blood contact.
A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?
- A. Decreased erythrocyte sedimentation rate
- B. Elevated serum bilirubin
- C. Elevated hemoglobin
- D. Elevated blood urea nitrogen
Correct Answer: B
Rationale: The correct answer is B: Elevated serum bilirubin. Hepatitis is characterized by liver inflammation, which can lead to impaired bilirubin metabolism and increased levels in the blood. Elevated serum bilirubin is a common finding in hepatitis. Decreased erythrocyte sedimentation rate (Choice A) is not specific to hepatitis. Elevated hemoglobin (Choice C) and elevated blood urea nitrogen (Choice D) are not typically associated with hepatitis and are more indicative of other conditions. In summary, elevated serum bilirubin is a key diagnostic marker for confirming a diagnosis of hepatitis.