Nokea
Priority Decision: A patient treated for vomiting is to begin oral intake when the symptoms have subside To promote rehydration
- A. the nurse plans to administer which fluid first?
- B. Water
- C. Hot tea
- D. Gatorade
Correct Answer: A
Rationale: Step 1: The priority is to administer fluids to rehydrate the patient.
Step 2: Intravenous fluids are not mentioned, so the nurse should start with oral fluids.
Step 3: Option A is the most appropriate choice as it addresses the need for fluid intake to promote rehydration.
Step 4: Water (Option B) lacks electrolytes that aid in rehydration.
Step 5: Hot tea (Option C) may irritate the stomach and not provide adequate hydration.
Step 6: Gatorade (Option D) contains electrolytes but may be too heavy for initial rehydration.
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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 family members of a patient with hepatitis A ask if there is anything that will prevent them from developing the disease. What is the best response by the nurse?
- A. No immunization is available for hepatitis A, nor are you likely to get the disease.'
- B. All family members should receive the hepatitis A vaccine to prevent or modify the infection.'
- C. Those who have had household or close contact with the patient should receive immune globulin.'
- D. Only those individuals who have had sexual contact with the patient should receive immunization.'
Correct Answer: C
Rationale: The correct answer is C: Those who have had household or close contact with the patient should receive immune globulin. This is because immune globulin can provide passive immunity to those exposed to hepatitis A, reducing the risk of developing the disease. Hepatitis A vaccine is not effective post-exposure, so it would not prevent disease in this scenario (option B). Option A is incorrect as there is a vaccine available for hepatitis A. Option D is incorrect because hepatitis A is primarily transmitted through fecal-oral route, not sexual contact.
An endoscopic biopsy of gastric mucosa reveals small intestinal type epithelium. This finding is most likely due to:
- A. chronic gastritis
- B. congenital heterotopia
- C. precancerous dysplasia
- D. metastatic carcinoma
Correct Answer: B
Rationale: The correct answer is B: congenital heterotopia. This is because the presence of small intestinal type epithelium in the gastric mucosa indicates ectopic tissue that is not normally found in the stomach. This condition is known as congenital heterotopia, where tissues from one organ are found in another due to developmental abnormalities.
A: Chronic gastritis would not lead to the presence of small intestinal type epithelium in the gastric mucosa.
C: Precancerous dysplasia refers to abnormal cellular changes that can progress to cancer but does not explain the presence of small intestinal type epithelium.
D: Metastatic carcinoma would involve the spread of cancer cells from another primary site, not the presence of ectopic tissue.
Which of the following is not a part of the small intestine?
- A. Duodenum
- B. Jejunum
- C. Ileum
- D. Colon
Correct Answer: D
Rationale: The correct answer is D: Colon. The colon is not a part of the small intestine; it is part of the large intestine. The small intestine consists of three parts: the duodenum, jejunum, and ileum. The duodenum is the first segment of the small intestine, followed by the jejunum and then the ileum. The colon, also known as the large intestine, comes after the small intestine in the digestive system. Therefore, the colon is not a part of the small intestine, making choice D the correct answer.
An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care?
- A. Monitor for signs of peritonitis.
- B. Treat with daily medicated enemas.
- C. Prepare for surgery to resect the involved colon.
- D. Provide a heating pad to apply to the left lower quadrant.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of peritonitis. Peritonitis is a serious complication of diverticulitis that can result from a rupture of inflamed diverticula leading to abdominal infection. Monitoring for signs such as severe abdominal pain, rigidity, and fever is crucial for early detection and prompt intervention. Option B is incorrect as daily medicated enemas are not the standard treatment for diverticulitis. Option C is also incorrect as surgery is usually reserved for complicated cases or recurrent attacks. Option D is incorrect because applying a heating pad may exacerbate inflammation and is not recommended in diverticulitis management.