Nokea
Identify one nursing intervention indicated for each of the following desired outcomes of tube feeding.
- A. Prevention of aspiration
- B. Prevention of diarrhea
- C. Maintenance of tube patency
- D. Maintenance of tube placement
Correct Answer: A
Rationale: The correct answer is A: Prevention of aspiration. This is essential in tube feeding to avoid the risk of food or liquid entering the lungs, causing aspiration pneumonia. Nursing interventions for this include ensuring proper positioning during and after feeding, checking residual volumes before each feeding, and using the appropriate tube size and placement.
Incorrect Choices:
B: Prevention of diarrhea - Diarrhea is not directly related to tube feeding complications, but rather to factors such as infection, medication side effects, or underlying conditions.
C: Maintenance of tube patency - While important, this focuses on ensuring the tube remains clear and functional, not directly related to preventing aspiration.
D: Maintenance of tube placement - Ensuring proper tube placement is crucial for effective feeding but does not directly address the risk of aspiration.
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A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially?
- A. Lying on the right side with legs straight
- B. Lying on the left side with knees bent
- C. Prone with the torso elevated
- D. Bent over with hands touching the floor
Correct Answer: B
Rationale: The correct answer is B: Lying on the left side with knees bent. This position allows for better visualization and access to the colon during the colonoscopy procedure. By lying on the left side, the client's colon is in a more optimal position for the scope to navigate through the colon. Additionally, bending the knees helps to relax the abdominal muscles and make the procedure more comfortable for the client.
Incorrect choices:
A: Lying on the right side with legs straight - This position does not provide optimal access to the colon and may make the procedure more difficult.
C: Prone with the torso elevated - This position is not suitable for a colonoscopy as it does not allow for proper access to the colon.
D: Bent over with hands touching the floor - This position is not recommended for a colonoscopy as it is not conducive to the procedure and may cause discomfort for the client.
After eating or drinking dairy products like cheese and milk, you have intestinal cramps, bloating and diarrhea. You most likely have
- A. lactose intolerance.
- B. diabetes mellitus, Type I.
- C. heartburn.
- D. peritonitis.
Correct Answer: A
Rationale: The correct answer is A: lactose intolerance. This is due to the inability to digest lactose, the sugar found in dairy products, leading to symptoms like intestinal cramps, bloating, and diarrhea. This is a common condition caused by a deficiency of lactase enzyme.
Choice B: Diabetes mellitus, Type I, is incorrect as it is an autoimmune condition affecting insulin production, not digestion of dairy products.
Choice C: Heartburn is incorrect as it is a symptom of acid reflux, not related to dairy product intolerance.
Choice D: Peritonitis is incorrect as it is an inflammation of the abdominal lining, usually caused by infection or injury, not related to dairy product intolerance.
A nurse is preparing an intervention plan for a client who is receiving tube feedings after an oral surgery. Which of the following measures can prevent improper infusion and assist in preventing vomiting?
- A. Consulting the physician and dietitian
- B. Administering the feedings at room temperature
- C. Changing the tube feeding container and tubing
- D. Checking the tube placement and gastric residual prior to feedings
Correct Answer: D
Rationale: The correct answer is D: Checking the tube placement and gastric residual prior to feedings. This is crucial to ensure proper placement of the tube and to assess if there is any undigested food in the stomach, which can lead to vomiting if fed through the tube. By checking these factors before administering feedings, the nurse can prevent complications.
A: Consulting the physician and dietitian is important but does not directly prevent improper infusion or vomiting.
B: Administering feedings at room temperature is a good practice but does not directly prevent vomiting.
C: Changing the tube feeding container and tubing may be necessary for hygiene but does not directly prevent improper infusion or vomiting.
In summary, checking the tube placement and gastric residual is essential in preventing vomiting and ensuring proper feeding, making it the correct choice.
The effects of parasympathetic stimulation on the GIT include:
- A. Constriction of the pylorus
- B. Contraction of the internal anal sphincter
- C. Contraction of the external anal sphincter
- D. Contraction of the gall bladder
Correct Answer: D
Rationale: The correct answer is D because parasympathetic stimulation causes the contraction of the gall bladder. This is due to the release of acetylcholine which stimulates the gall bladder to contract and release bile into the duodenum to aid in digestion. Choices A, B, and C are incorrect as parasympathetic stimulation does not cause constriction of the pylorus, contraction of the internal anal sphincter, or contraction of the external anal sphincter.
The stomach contractions, which move the chyme from near the periphery of the stomach toward the pyloric sphincter, are called
- A. the pyloric pump.
- B. peristaltic waves.
- C. mixing waves.
- D. mass movements.
Correct Answer: C
Rationale: The correct answer is C: mixing waves. Mixing waves are the stomach contractions that help mix the chyme near the periphery of the stomach and move it towards the pyloric sphincter for further digestion. Peristaltic waves (B) are rhythmic contractions that propel food through the digestive system, not specifically in the stomach. The pyloric pump (A) is not a recognized term in gastrointestinal physiology. Mass movements (D) refer to contractions in the large intestine that move feces towards the rectum, not in the stomach.