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An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to
- A. offer ice chips to suck PRN.
- B. provide mouth care every 1 to 2 hours.
- C. irrigate the tube with normal saline every 8 hours.
- D. keep the patient supine with the head of the bed elevated 30 degrees.
Correct Answer: B
Rationale: The correct answer is B: provide mouth care every 1 to 2 hours. This is crucial to maintain oral hygiene and comfort for the patient with an NG tube to prevent complications like dry mouth and infection. Offering ice chips (choice A) may worsen the obstruction. Irrigating the tube with normal saline (choice C) can disrupt the bowel and is not recommended. Keeping the patient supine with the head of the bed elevated (choice D) is a general measure but not specific to NG tube care.
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What manifestation in the patient does the nurse recognize as an early sign of hepatic encephalopathy?
- A. Manifests asterixis
- B. Becomes unconscious
- C. Has increasing oliguria
- D. Is irritable and lethargic
Correct Answer: D
Rationale: The correct answer is D: Is irritable and lethargic. Early signs of hepatic encephalopathy often include behavioral changes like irritability and lethargy due to impaired brain function from liver dysfunction. This is because the liver is unable to properly detoxify ammonia, leading to its accumulation in the bloodstream and affecting brain function. Asterixis, unconsciousness, and oliguria are more severe manifestations seen in later stages of hepatic encephalopathy. Therefore, recognizing irritability and lethargy in a patient would prompt early intervention to prevent further progression of hepatic encephalopathy.
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.
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.
The stomach:
- A. Secretes pepsinogen, intrinsic factor and pepsin.
- B. Secretion increase following total vagus nerve cut.
- C. PH is always 7.2.
- D. Secretes intrinsic factor which is essential for vitamin B12 absorption.
Correct Answer: D
Rationale: The correct answer is D because the stomach secretes intrinsic factor, which is essential for vitamin B12 absorption in the small intestine. This is crucial for preventing vitamin B12 deficiency and maintaining neurological health. The other choices are incorrect because A is partially true but not the main function of the stomach, B is false as total vagus nerve cut decreases stomach secretion, and C is false as the stomach pH varies from acidic (around 1.5-3.5) depending on food intake.
The hydrogen ions that form hydrochloric acid of the stomach come from
- A. lactic acid.
- B. carbonic acid.
- C. citric acid.
- D. acetic acid.
Correct Answer: B
Rationale: The correct answer is B: carbonic acid. Carbonic acid is produced when carbon dioxide reacts with water in the stomach, forming hydrogen ions that combine with chloride ions to create hydrochloric acid. Lactic acid (A), citric acid (C), and acetic acid (D) do not directly contribute to the formation of hydrochloric acid in the stomach. Therefore, they are incorrect choices for this question.