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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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Mumps is inflammation of the ______ salivary gland caused by a virus.
- A. buccal
- B. sublingual
- C. submandibular
- D. parotid
Correct Answer: D
Rationale: The correct answer is D: parotid. Mumps is inflammation of the parotid salivary gland. The parotid gland is the largest salivary gland located near the ear. It is commonly affected by the mumps virus, causing swelling and pain.
Rationale:
1. The parotid gland is the main salivary gland affected by the mumps virus.
2. The other choices, buccal, sublingual, and submandibular glands, are not typically associated with mumps.
3. Understanding the anatomical location and function of the salivary glands helps in identifying the correct answer.
A patient asks the nurse about taking phentermine and topiramate (Qsymia) for weight loss. To avoid side effects
- A. it is important for the nurse to determine whether the patient has a history of
- B. glaucoma.
- C. hypertension.
- D. valvular heart disease.
Correct Answer: A
Rationale: The correct answer is A because it is essential to determine if the patient has a history of certain conditions before prescribing Qsymia. This medication can worsen glaucoma (not just a history of it) making option B incorrect. Option C is incorrect because Qsymia can actually help manage hypertension. Option D is incorrect because while valvular heart disease can be a concern, it is not the primary factor to consider before prescribing this medication.
Priority Decision: In instituting a bowel training program for a patient with fecal incontinence, what should the nurse first plan to do?
- A. Teach the patient to use a perianal pouch.
- B. Insert a rectal suppository at the same time every morning.
- C. Place the patient on a bedpan 30 minutes before breakfast.
- D. Assist the patient to the bathroom at the time of the patient's normal defecation.
Correct Answer: D
Rationale: The correct answer is D because assisting the patient to the bathroom at the time of their normal defecation helps establish a routine for bowel movements, which is crucial in bowel training. This step maximizes the chances of success by utilizing the body's natural cues. Teaching the patient to use a perianal pouch (A) does not address the underlying issue of incontinence. Inserting a rectal suppository (B) may provide temporary relief but does not promote long-term bowel control. Placing the patient on a bedpan (C) at a specific time does not actively involve the patient in the process of bowel training.
A hiatal hernia is a weakness in the _____ muscle, which allows a portion of the digestive tract to enter the thoracic cavity.
- A. diaphragm
- B. stomach
- C. intestinal
- D. thoracic wall
Correct Answer: A
Rationale: The correct answer is A: diaphragm. The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. A hiatal hernia occurs when the stomach pushes through the opening in the diaphragm known as the esophageal hiatus, allowing a portion of the stomach to enter the thoracic cavity. The other choices, B: stomach, C: intestinal, and D: thoracic wall, are incorrect because a hiatal hernia specifically involves a weakness in the diaphragm muscle, not in these other structures. The stomach is the organ affected by the hernia, but the primary issue lies in the diaphragm's weakness. The intestinal and thoracic wall choices are not directly related to the development of a hiatal hernia.
A client with an ileostomy wants to know why to avoid fibrous vegetables. What should be the nurse's response?
- A. They cause gas formation.
- B. They cause stomal obstruction.
- C. They are difficult to digest.
- D. They increase the risk of diarrhea.
Correct Answer: B
Rationale: The correct answer is B because fibrous vegetables can potentially cause stomal obstruction in clients with an ileostomy due to their indigestible nature, leading to blockages in the stoma. This can result in severe complications and require medical intervention. Gas formation (choice A) is a common issue with high-fiber foods but is not specific to fibrous vegetables. Fibrous vegetables are not necessarily difficult to digest (choice C) for most individuals, although they may be harder for those with reduced gut function. While fibrous vegetables may contribute to loose stools, they do not directly increase the risk of diarrhea (choice D) in the same way they can cause stomal obstruction.