Nokea
The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections
- B. Vitamin B6 injections
- C. An antibiotic
- D. An antacid
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is needed for Vitamin B12 absorption. Since the stomach lining produces less intrinsic factor after gastric surgery, the client cannot absorb B12 orally. Therefore, B12 injections are necessary to bypass the need for intrinsic factor. Vitamin B6 injections (B) are not indicated for pernicious anemia. Antibiotics (C) and antacids (D) are not relevant to the treatment of pernicious anemia.
You may also like to solve these questions
When assessing the client with celiac disease, the nurse can expect to find which of the following?
- A. Steatorrhea
- B. Jaundiced sclerae
- C. Clay-colored stools
- D. Widened pulse pressure
Correct Answer: A
Rationale: The correct answer is A: Steatorrhea. In celiac disease, the small intestine is unable to absorb nutrients properly due to gluten intolerance, leading to fat malabsorption. Steatorrhea is a common symptom characterized by foul-smelling, greasy, and bulky stools. Jaundiced sclerae (B) are associated with liver dysfunction, not celiac disease. Clay-colored stools (C) may indicate issues with the liver or bile ducts, not celiac disease. Widened pulse pressure (D) is not typically a direct symptom of celiac disease but may be seen in conditions like aortic regurgitation.
A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
- A. Swelling of the abdomen
- B. Bloody diarrhea
- C. Vomiting blood
- D. An elevated temperature and arise in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Vomiting blood. When the esophageal balloon of the Sengstaken-Blakemore tube is deflated, the risk of esophageal variceal bleeding increases. Vomiting blood indicates active bleeding and requires immediate intervention. Swelling of the abdomen (A) is not directly related to deflating the balloon. Bloody diarrhea (B) is not a common complication of deflating the balloon. An elevated temperature and a rise in blood pressure (D) are not typical signs of complications related to the deflation of the esophageal balloon.
Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis?
- A. The client maintains a daily record of intake and output.
- B. The client verbalizes the importance of small, frequent feedings.
- C. The client uses a heating pad to decrease abdominal cramping.
- D. The client accepts that a colostomy is inevitable at some time in his life.
Correct Answer: B
Rationale: The correct answer is B: The client verbalizes the importance of small, frequent feedings. This is appropriate for a client with ulcerative colitis because small, frequent feedings help reduce gastrointestinal distress and maintain proper nutrition. Clients with ulcerative colitis often have difficulty tolerating large meals, so small, frequent feedings can help prevent exacerbation of symptoms.
A: Recording intake and output is important for certain conditions but not specifically for ulcerative colitis.
C: Using a heating pad may provide temporary relief for abdominal cramping but does not address the underlying issue of ulcerative colitis.
D: Accepting a colostomy is not an expected outcome for ulcerative colitis treatment unless all other options have failed.
Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to
- A. Confirm proper nasogastric tube placement.
- B. Observe gastric contents.
- C. Assess fluid and electrolyte status.
- D. Evaluate absorption of the last feeding.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): By assessing for gastric residual before administering another feeding through the nasogastric tube, the nurse can evaluate absorption of the last feeding. If there is a significant amount of residual, it may indicate poor absorption, which could lead to complications such as aspiration. This assessment helps in determining the appropriate timing and amount of the next feeding to prevent complications.
Summary of Incorrect Choices:
A: Confirming proper nasogastric tube placement is typically done using other methods like pH testing or X-ray. This assessment does not directly relate to evaluating absorption.
B: Observing gastric contents may provide information about the patient's gastric secretions but does not specifically help in evaluating the absorption of the last feeding.
C: Assessing fluid and electrolyte status is important but not the primary purpose of checking gastric residual before administering a feeding. This assessment is more focused on monitoring the patient's overall hydration and electrolyte balance.
The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?
- A. Increase the amount of sodium in the diet.
- B. Limit the amount of fluids consumed.
- C. Encourage frequent ambulation.
- D. Administer magnesium antacids.
Correct Answer: B
Rationale: The correct answer is B: Limit the amount of fluids consumed. In cirrhosis with ascites and excess fluid volume, limiting fluid intake helps reduce fluid overload and prevent further accumulation of fluid in the body. Excess fluid can worsen ascites, leading to complications like respiratory distress and electrolyte imbalances. Increasing sodium intake (A) would worsen fluid retention. Encouraging ambulation (C) is important but not directly related to managing ascites. Administering magnesium antacids (D) is not necessary for addressing fluid volume excess.