Nokea
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.
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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 patient experienced a blood transfusion reaction. How should the nurse explain to the patient the cause of the hemolytic jaundice that occurred?
- A. Results from hepatocellular disease
- B. Due to a malaria parasite breaking apart red blood cells (RBCs)
- C. Results from decreased flow of bile through the liver or biliary system
- D. Due to increased breakdown of RBCs that caused elevated serum unconjugated bilirubin
Correct Answer: D
Rationale: The correct answer is D. Hemolytic jaundice in a blood transfusion reaction is due to increased breakdown of red blood cells (RBCs) causing elevated serum unconjugated bilirubin. This occurs when the patient's immune system reacts to the transfused blood, leading to destruction of RBCs. The breakdown of these cells releases hemoglobin, which is metabolized into bilirubin. This unconjugated bilirubin then accumulates in the blood, causing jaundice.
Choice A is incorrect because hepatocellular disease does not directly cause hemolytic jaundice. Choice B is incorrect as malaria parasite breaking apart RBCs leads to hemolysis, not a blood transfusion reaction. Choice C is incorrect as decreased bile flow through the liver or biliary system typically causes obstructive jaundice, not hemolytic jaundice.
While a female client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?
- A. Irrigate the tube with warm water.
- B. Advance the tube into the intestine.
- C. Apply intermittent suction to the tube.
- D. Withdraw the obstruction with a 30-ml syringe.
Correct Answer: A
Rationale: The correct answer is A: Irrigate the tube with warm water. This is the correct action because irrigating the NG tube with warm water can help dislodge the clog and clear the obstruction. Here is a step-by-step rationale:
1. Gather necessary supplies: warm water, syringe, and towel.
2. Disconnect the tube from the feeding pump.
3. Draw up warm water into the syringe.
4. Gently insert the syringe into the tube and slowly push the warm water to flush out the clog.
5. Repeat the process as needed until the tube is clear.
Other choices are incorrect:
B: Advancing the tube into the intestine can be dangerous and should not be done without proper medical supervision.
C: Applying intermittent suction may not effectively clear the clog and could potentially worsen the situation.
D: Using a 30-ml syringe to withdraw the obstruction may not be as effective as irrigating with warm water.
The optimum pH for trypsin and chymotrypsin is about
- A. 1-3.
- B. 5-7.
- C. 7-9.
- D. 10-12.
Correct Answer: C
Rationale: The correct answer is C (7-9) because trypsin and chymotrypsin are proteolytic enzymes that function optimally in slightly basic environments. At pH 7-9, these enzymes maintain their structural integrity and catalytic activity. Choices A, B, and D are incorrect because trypsin and chymotrypsin are not acidic enzymes, so pH ranges 1-3 and 10-12 would denature and inactivate them, while pH 5-7 is still on the acidic side, not optimal for these enzymes.
The accessory digestive organs include all of the following, EXCEPT:
- A. tongue
- B. liver
- C. pancreas
- D. stomach
Correct Answer: D
Rationale: The correct answer is D, stomach. The stomach is not considered an accessory digestive organ as it is part of the gastrointestinal tract. The accessory digestive organs aid in the digestion process but are not part of the tract itself. The tongue, liver, and pancreas are all considered accessory digestive organs as they play crucial roles in digestion, such as producing enzymes and bile. The stomach's main function is to store and break down food through mechanical and chemical digestion, making it a primary organ in the digestive system rather than an accessory one.