Nokea
The nervous system or systems that can control peristalsis in the inferior esophagus, stomach, small intestine and large intestine is (are) the
- A. somatic motor nervous system.
- B. sympathetic nervous system.
- C. sympathetic and parasympathetic nervous systems.
- D. autonomic and somatic motor nervous systems.
Correct Answer: C
Rationale: The correct answer is C because peristalsis, the involuntary movement of the digestive tract, is controlled by both sympathetic and parasympathetic nervous systems. The parasympathetic nervous system stimulates peristalsis, while the sympathetic nervous system inhibits it. Choice A is incorrect because the somatic motor nervous system controls voluntary movements, not peristalsis. Choice B is incorrect because the sympathetic nervous system inhibits peristalsis. Choice D is incorrect because the somatic motor nervous system does not control peristalsis in the digestive tract; it controls skeletal muscle movements.
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Which part of the digestive system is responsible for the absorption of water and electrolytes?
- A. Small intestine
- B. Large intestine
- C. Stomach
- D. Pancreas
Correct Answer: B
Rationale: The correct answer is B: Large intestine. The large intestine is responsible for the absorption of water and electrolytes from the remaining indigestible food matter that passes through the small intestine. It reabsorbs water and electrolytes to maintain the body's fluid balance. The small intestine primarily absorbs nutrients and vitamins, while the stomach is responsible for the initial digestion of food and the pancreas secretes digestive enzymes into the small intestine. Therefore, the large intestine is the correct choice for water and electrolyte absorption in the digestive system.
Care for which of these clients is most appropriate to assign to the LPN/LVN, under the supervision of an RN?
- A. A client with oral cancer who is scheduled in the morning for glossectomy
- B. An obese client returned from surgery following a vertical banded gastroplasty
- C. A client with anorexia nervosa with muscle weakness and decreased urine output
- D. A client with intractable nausea and vomiting related to chemotherapy
Correct Answer: D
Rationale: The correct answer is D because the LPN/LVN can provide care for a client with intractable nausea and vomiting related to chemotherapy under the supervision of an RN. The LPN/LVN can administer prescribed antiemetic medications, monitor the client's response, assess for dehydration, and provide comfort measures. This task falls within the scope of practice for an LPN/LVN and does not require the advanced assessment and intervention skills of an RN.
Choice A is incorrect because a client undergoing a glossectomy for oral cancer requires complex post-operative care that is beyond the scope of practice for an LPN/LVN.
Choice B is incorrect because post-operative care for an obese client following a vertical banded gastroplasty involves monitoring for complications such as leaks or infections, which require the expertise of an RN.
Choice C is incorrect because a client with anorexia nervosa with muscle weakness and decreased urine output may have underlying medical issues that require an RN's assessment and intervention skills
Priority Decision: A patient returns to the surgical unit with a nasogastric (NG) tube to low intermittent suction, IV fluids, and a Jackson-Pratt drain at the surgical site following an exploratory laparotomy and repair of a bowel perforation. Four hours after admission, the patient experiences nausea and vomiting. What is a priority nursing intervention for the patient?
- A. Assess the abdomen for distention and bowel sounds.
- B. Inspect the surgical site and drainage in the Jackson-Pratt.
- C. Check the amount and character of gastric drainage and the patency of the NG tube.
- D. Administer prescribed prochlorperazine (Compazine) to control the nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Check the amount and character of gastric drainage and the patency of the NG tube. This is the priority nursing intervention because the patient is experiencing nausea and vomiting, which could indicate potential complications related to the NG tube, such as blockage or displacement. By checking the gastric drainage and NG tube patency, the nurse can assess if the patient's symptoms are related to these issues and take appropriate actions to address them.
Choice A is incorrect because assessing the abdomen for distention and bowel sounds is important but not the priority in this situation where the patient is experiencing nausea and vomiting. Choice B is incorrect as inspecting the surgical site and drainage in the Jackson-Pratt drain is also important but not as urgent as checking the NG tube patency in this case. Choice D is incorrect as administering medication should not be the first action taken without first assessing the underlying cause of the symptoms.
Which patient has the highest risk for poor nutritional balance related to decreased ingestion?
- A. Tuberculosis infection
- B. Draining decubitus ulcers
- C. Malabsorption syndrome
- D. Severe anorexia resulting from radiation therapy
Correct Answer: D
Rationale: The correct answer is D: Severe anorexia resulting from radiation therapy. This patient has the highest risk for poor nutritional balance due to the severe anorexia caused by the treatment. Radiation therapy often leads to loss of appetite, making it difficult for the patient to ingest adequate nutrients, resulting in malnutrition.
A: Tuberculosis infection does not necessarily directly cause decreased ingestion, as appetite may vary among patients.
B: Draining decubitus ulcers may lead to protein and fluid loss but not necessarily decreased ingestion.
C: Malabsorption syndrome affects the absorption of nutrients but does not directly relate to decreased ingestion.
The nurse is preparing to administer liquid laxative to a patient in preparation for a colonoscopy. Which action should the nurse take?
- A. Offer a small snack.
- B. Take the patient's temperature.
- C. Mix the laxative with orange juice.
- D. Chill the laxative and pour it over ice.
Correct Answer: D
Rationale: The correct answer is D because chilling the laxative and pouring it over ice can help improve its taste and make it more palatable for the patient. This can encourage the patient to consume the laxative as needed for the colonoscopy preparation. Offering a small snack (choice A) may interfere with the effectiveness of the laxative. Taking the patient's temperature (choice B) is not relevant to administering a laxative. Mixing the laxative with orange juice (choice C) may alter its effectiveness and is not recommended.