Nokea
In caring for a patient with gastric bleeding who has a nasogastric (NG) tube in place, the nurse expects to see which intervention for the nasogastric tube included in the plan of care?
- A. clamp for 10 minutes every hour.
- B. keep the patent with irrigation.
- C. frequently reposition to the opposite nostril.
- D. change every 72 hours.
Correct Answer: B
Rationale: Irrigating the NG tube as needed will keep the tube patent and ensure effective decompression.
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In reinforcing a teaching plan to present to a group of older adults regarding the prevention of esophageal cancer, the nurse would include which significant information?
- A. cessation of smoking.
- B. Frequent monitoring for Barrett's esophagus
- C. regular checkups if dysphagia is present.
- D. reducing excessive weight.
- E. limiting alcohol consumption.
- F. reduction of consumption of citrus fruits.
Correct Answer: A,B,C,E
Rationale: Preventive measures include cessation of smoking and alcohol consumption, monitoring for Barrett's esophagus, and medical evaluation of dysphagia. Weight and reduction of citrus fruits are noncontributory to prevention of esophageal cancer.
Flexible sigmoidoscopy should be performed every years.
- A. 5
Correct Answer: 5
Rationale: Flexible sigmoidoscopy should be performed every 5 years. Endoscopy of the lower GI tract allows visualization and, if indicated, access to obtain biopsy specimens of tumors, polyps, or ulcerations of the anus, rectum, and sigmoid colon. The lower GI tract is difficult to visualize radiographically, but sigmoidoscopy allows direct visualization.
The patient has come to the PACU following an ileostomy for the treatment of ulcerative colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma. What should be the nurse's initial action?
- A. Turn patient to right side.
- B. Give patient ice chips to moisten mouth.
- C. Attach NG tube to suction.
- D. Irrigate NG tube.
Correct Answer: C
Rationale: Initially, the NG tube should be attached to suction to decompress the stomach and prevent nausea. Assessing the tube for the need of future irrigation will be part of the postoperative care.
A male patient reports that he will never adjust to his colostomy. Which is the best action for the nurse in this situation?
- A. Encourage him to express his concern.
- B. Suggest that he discuss his concerns with his physician.
- C. Counsel him that everything will be all right.
- D. Assure him that his concerns will diminish when he is able to care for his colostomy.
Correct Answer: A
Rationale: When a colostomy is performed, the patient or significant other should be able to verbalize concerns about the ostomy to the nurse.
A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia?
- A. Strangulated
- B. Hiatal
- C. Ventral
- D. Umbilical
Correct Answer: A
Rationale: The hernia is strangulated when the blood supply and intestinal flow are occluded, which results in pain and distention.