Nokea
The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be
- A. Discarded properly and recorded as output on the client's intake and output record.
- B. Poured into the nasogastric tube through a syringe with the plunger removed.
- C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
- D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.
Correct Answer: B
Rationale: The correct answer is B because pouring the 40 mL of gastric aspirate back into the nasogastric tube through a syringe with the plunger removed ensures the undigested formula is returned to the stomach for digestion. This method maintains the balance of electrolytes and nutrients and prevents potential complications.
Choice A is incorrect because discarding the aspirate without returning it to the stomach can lead to electrolyte imbalances and nutritional deficiencies.
Choice C is incorrect because mixing the aspirate with formula before administering it can cause inaccurate dosing and potential nutrient interactions.
Choice D is incorrect because diluting the aspirate with water and forcibly injecting it back into the stomach can cause discomfort and potential complications for the client.
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Cholestyramine resin (Questran Light) is prescribed for the client with an elevated serum cholesterol level. The nurse would instruct the client to take the medication
- A. After meals.
- B. Mixed with fruit juice.
- C. Via rectal suppository.
- D. At least 3 hours before meals.
Correct Answer: B
Rationale: The correct answer is B: Mixed with fruit juice. Cholestyramine resin should be taken mixed with a liquid, such as fruit juice, to prevent esophageal irritation and improve absorption. Taking it with a meal can interfere with nutrient absorption. Taking it via rectal suppository is incorrect as it is an oral medication. Taking it at least 3 hours before meals is not necessary and may lead to decreased effectiveness. Mixing it with fruit juice helps improve tolerability and effectiveness.
A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively?
- A. High-protein
- B. High-carbohydrate
- C. Low-calorie
- D. Low-residue
Correct Answer: D
Rationale: The correct answer is D: Low-residue. After colostomy surgery, the bowel needs time to heal. A low-residue diet helps reduce the amount of undigested food passing through the colon, easing digestion and minimizing strain on the stoma. This diet typically includes easily digestible foods like white bread, rice, pasta, and well-cooked vegetables. High-protein (choice A) and high-carbohydrate (choice B) diets can be harder to digest and may cause discomfort. A low-calorie diet (choice C) is not necessary during the initial postoperative period when the focus should be on promoting healing and comfort.
A nurse is providing the client with biliary obstruction a simple overview of the anatomy of the liver and gallbladder. The nurse tells the client that normally the liver stores bile in the gallbladder, which is connected to the liver by the?
- A. Liver canaliculi
- B. Common bile duct
- C. Cystic duct
- D. Right hepatic duct.
Correct Answer: C
Rationale: The correct answer is C: Cystic duct. The cystic duct connects the gallbladder to the common bile duct, through which bile flows from the liver to the gallbladder for storage. The liver canaliculi are tiny channels within the liver where bile is produced. The common bile duct is the main duct through which bile flows from the liver to the small intestine. The right hepatic duct is one of the ducts that collect bile from the liver but does not directly connect to the gallbladder. Therefore, the cystic duct is the correct choice as it specifically links the gallbladder to the common bile duct for bile transportation.
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.
The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates best understanding of the medication therapy?
- A. The cimetidine (Tagamet) will cause me to produce less stomach acid.
- B. Sucralfate (Carafate) will change the fluid in my stomach.
- C. Antacids will coat my stomach.
- D. Omeprazole (Prilosec) will coat the ulcer and help it heal.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Cimetidine (Tagamet) is an H2 receptor antagonist that decreases stomach acid production.
2. Peptic ulcer disease is often caused by excessive stomach acid.
3. By decreasing stomach acid, cimetidine helps to heal the ulcer and prevent further damage.
4. Understanding this mechanism of action demonstrates the client's comprehension of the medication therapy.
Summary:
B: Sucralfate does not change stomach fluid; it forms a protective barrier over the ulcer.
C: Antacids neutralize stomach acid but do not coat the stomach.
D: Omeprazole reduces stomach acid production, not coats the ulcer.