Nokea
The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.
- A. 6 hours
Correct Answer: A
Rationale: Step 1: 2 * 8 oz = 16 oz Step 2: 1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours
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The nurse is managing the care of a client needing gastrointestinal suction and decompression with a Levin tube. Place the steps of initiating suction and decompression in the order the nurse should perform them.
- A. Insert the gastric decompression tube.
- B. Locate the suction source.
- C. Connect the decompression tube to the suction.
- D. Select suction according to health care provider prescription.
Correct Answer: B,D,A,C
Rationale: The nurse should locate the suction source, usually a wall outlet or portable machine. The nurse should then adjust the suction level on the wall outlet or portable machine to provide the amount and frequency of suction specified by the primary provider. The nurse should select intermittent high, low, or continuous suction when using a Salem sump tube; the nurse should select low intermittent suction when using a Levin tube because the single lumen may adhere to the lining of the stomach during continuous suction (if the tube is used only to obtain specimens for diagnostic purposes, manual suction may be achieved by attaching a syringe to the end of the tube and drawing back on the plunger). Finally, the nurse should insert the gastric decompression tube in accordance with accepted standards and connect it to the suction.
The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response?
- A. I can arrange a nutritional consultation.
- B. Cold liquids may help soothe the sensitivity.
- C. An anesthetic mouthwash may be used, but I will need to consult with the primary provider.
- D. A special diet may be necessary based on your ability to chew and swallow.
- E. Your doctor may prescribe a systemic analgesic for pain relief if necessary.
Correct Answer: A,C,D,E
Rationale: When responding to a client reporting severe mouth sensitivity due to oral cancer, the nurse should inform the client of possible options for managing the sensitivity. These include nutritional consultations, the use of anesthetic mouthwash if approved by the primary provider, the formulation of a special diet around the client's ability to chew and swallow, and a systemic analgesic for pain relief if the provider deems it necessary. It is inaccurate for the nurse to respond that cold liquids may soothe the sensitivity, because cold and hot liquids may increase the discomfort of sensitive oral tissues.
Which assessment finding is most indicative of dumping syndrome in a postgastrectomy client?
- A. Abdominal distention, elevated temperature, weakness before eating
- B. Constipation, rectal bleeding following bowel movements
- C. Persistent loose stools, chills, hiccups after eating
- D. Weakness, diaphoresis, diarrhea 90 minutes after eating
Correct Answer: D
Rationale: Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
The nurse is preparing to administer famotidine to a client with gastroesophageal reflux disease. Which safety warning should the nurse consider when administering the medication?
- A. Do not allow client to take maximum dose for more than 2 weeks without medical consultation.
- B. Review client's cardiac status and sodium restrictions.
- C. Do not give other oral drugs within 1 to 2 hours of administering the medication.
- D. Be aware that long-term use may be associated with bone fractures
Correct Answer: A
Rationale: The safety warning that the nurse should consider is that the client should not take the maximum dose of famotidine for more than 2 weeks without medical consultation, because it is a histamine H2 antagonist. Reviewing cardiac status and sodium restrictions is a consideration for sodium bicarbonate. Not giving oral drugs within 1 to 2 hours is a consideration for antacids. Long-term use being associated with bone fractures is a consideration for proton pump inhibitors.
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?
- A. I will eat two large meals a day, instead of three.
- B. I will eliminate bothersome foods from my diet.
- C. I will plan to sleep flat without pillows.
- D. I will start taking a nap after meals, when possible.
Correct Answer: B
Rationale: Irritating foods such as spices, caffeine, and alcohol should be avoided because doing so will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.