Nokea
The nurse explains that the chief enzyme of gastric juice, is activated by hydrochloric acid to begin digestion of protein.
- A. pepsin
Correct Answer: pepsin
Rationale: Pepsin is activated by the hydrochloric acid to break down protein for digestion.
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A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia?
- A. Strangulated
- B. Hiatal
- C. Ventral
- D. Umbilical
Correct Answer: A
Rationale: The hernia is strangulated when the blood supply and intestinal flow are occluded, which results in pain and distention.
What should a nurse do when obtaining a stool specimen to be examined for ova and parasites?
- A. Use an oil retention enema to facilitate collection.
- B. Refrigerate the specimen immediately.
- C. Obtain three different stool specimens on subsequent days.
- D. Check the specimen for the presence of occult blood.
Correct Answer: C
Rationale: Diagnosing a parasitic infection requires three different stool specimens on subsequent days. Use only normal saline or tap water enemas to prevent alteration of results.
Due to frequent bouts of constipation, the nurse examines the bedfast nursing home resident for ulceration of the anus, called anal
- A. fissure
Correct Answer: fissure
Rationale: Ulceration and laceration of the anal skin can occur because of overstretching with the passing of constipated stool.
The nurse takes into consideration that long-term use of antibiotics can cause an antibiotic-associated pseudomembranous colitis from the organism
- A. Clostridium difficile
Correct Answer: Clostridium difficile
Rationale: C. difficile causes a type of colitis from long-term antibiotic use to which older adults are extremely susceptible.
The nurse caring for a patient with Crohn disease will closely monitor the urinary output to ensure that the patient is excreting at least mL/day.
- A. 1500
Correct Answer: 1500
Rationale: The output of 1500 mL a day indicates good kidney perfusion. The disease allows such dramatic fluid loss that a constant watch on I&O is a major nursing intervention.