Nokea
A small-bore feeding tube is placed. Which technique will the nurse use tobestverify tube placement?
- A. X-ray
- B. pH testing
- C. Auscultation
- D. Aspiration of contents
Correct Answer: A
Rationale: At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. X-ray allows for direct visualization of the tube's placement within the gastrointestinal tract, ensuring it is correctly positioned in the stomach without any risk of inadvertent placement in the lungs, pharynx, or esophagus. This method provides a definitive confirmation of tube placement, which is crucial for patient safety during enteral feeding. While pH testing and aspiration of contents can be useful as supplementary methods, x-ray remains the gold standard for verifying tube placement due to its precision and accuracy. Auscultation, on the other hand, is no longer recommended as a reliable method for tube placement verification, as it may lead to misinterpretation of sounds and potential errors in placement assessment.
You may also like to solve these questions
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
A nurse is teaching a patient about the largeintestine in elimination. In which order will the nurse list the structures, starting with the first portion?
- A. Cecum, ascending, transverse, descending, sigmoid, and rectum
- B. Ascending, transverse, descending, sigmoid, rectum, and cecum
- C. Cecum, sigmoid, ascending, transverse, descending, and rectum
- D. Ascending, transverse, descending, rectum, sigmoid, and cecum
Correct Answer: A
Rationale: The order in which the structures of the large intestine are listed starting with the first portion is as follows: cecum (the pouch where the large intestine begins), ascending colon (runs vertically up the right side of the abdomen), transverse colon (crosses horizontally from the right side of the abdomen to the left), descending colon (descends vertically down the left side of the abdomen), sigmoid colon (the S-shaped curve that leads into the rectum), and rectum (the final portion where feces are stored before being eliminated from the body). Therefore, option A provides the correct order of structures in the large intestine during elimination.
Draw up prescribed amount of sterile solution ordered.
- A. 3, 2, 6, 1, 5, 4
- B. 5, 6, 1, 2, 3, 4
- C. 1, 5, 6, 3, 2, 4
- D. 6, 5, 1, 3, 2, 4
Correct Answer: D
Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.
A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this patient?
- A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
- B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
- C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
- D. The human papillomavirus (HPV), which causes condylomata acuminata, cannot be transmitted during oral sex.
Correct Answer: A
Rationale: The most appropriate information for the nurse to tell the patient is option A, which states that this condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually. Condylomata acuminata, or genital warts, is caused by the human papillomavirus (HPV). Certain strains of HPV, specifically types 16 and 18, are considered high-risk strains that can lead to cervical cancer in women. Therefore, regular Pap tests are crucial for early detection of any cervical changes that could indicate pre-cancerous or cancerous lesions. It is important for the patient to be informed about this risk and the importance of regular screening to monitor her cervical health.
A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.
- A. Adherence to the exercise plan
- B. Overall psychological functioning
- C. Integrity of surgical drains
- D. Understanding of cancer E) Use of the breast prosthesis
Correct Answer: B
Rationale: B. Overall psychological functioning: It is crucial for the home care nurse to assess the patient's overall psychological functioning after a total mastectomy without reconstruction. The patient may be experiencing emotional distress, body image disturbances, anxiety, or depression related to the surgery and changes in physical appearance. The nurse should evaluate the patient's coping mechanisms, emotional well-being, and any signs of psychological implications to provide appropriate support and referral for mental health services if needed.