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The nurse is taking care of a client that is scheduled to undergo a gastric analysis at 8:00 AM tomorrow. Which should be included in the client's plan of care?
- A. Instruct the client that she should not eat or drink anything after midnight.
- B. Teach the client that in case she feels hungry, she can chew some gum.
- C. Instruct the client that she needs to be on bed rest for 2 hours after the procedure.
- D. Tell the client that she is allowed to smoke 1 hour prior to surgery.
Correct Answer: A
Rationale: Fasting after midnight (A) ensures accurate gastric analysis results. Chewing gum (B), bed rest (C), and smoking (D) are not appropriate.
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The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated?
- A. Administering gastrografin for an upper GI x-ray.
- B. An exploratory laparotomy procedure.
- C. Administering milk of magnesia following an upper GI study.
- D. An abdominal CT scan.
Correct Answer: C
Rationale: Milk of magnesia (C) is contraindicated in suspected bowel perforation as it may worsen the condition by increasing intestinal motility or causing further leakage. Gastrografin (A), laparotomy (B), and CT scans (D) are appropriate diagnostic or therapeutic measures.
The nurse supervises a student nurse giving medications through a nasogastric tube (NGT) to a client receiving continuous enteral feeding. Which actions by the student require follow-up by the nurse? Select all that apply.
- A. Gives each medication separately
- B. Verifies placement of the NGT prior to medication administration
- C. Elevates the head of the bed to 15 degrees
- D. Adds crushed medications directly to a tube feeding
- E. Crushes each tablet into a fine powder
Correct Answer: C,D
Rationale: Elevating the head of the bed to only 15 degrees (C) is insufficient to prevent aspiration; 30-45 degrees is recommended. Adding crushed medications to the tube feeding (D) can clog the tube or alter medication efficacy. Other actions (A, B, E) are correct.
The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply.
- A. I will not be able to eat or drink anything for six to eight hours before this procedure.
- B. I will have to do a bowel prep before this procedure.
- C. Someone will have to drive me home after this procedure.
- D. I should notify my physician if I have abdominal pain and distention for one or two days following this procedure.
- E. I can expect to have white stools one to two days following this procedure.
Correct Answer: B,D,E
Rationale: Bowel prep (B) is not typically required for ERCP. Persistent pain and distention (D) post-ERCP require immediate notification, not delayed. White stools (E) are not expected post-ERCP. Fasting (A) and needing a driver (C) are correct.
Which of the following most impacts a client's food preferences?
- A. Culture and cultural background
- B. The frequency of grocery shopping
- C. The availability of foods locally
- D. The costs associated with food
Correct Answer: A
Rationale: Culture and cultural background (A) most significantly influence food preferences due to traditions, beliefs, and dietary practices.
The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
- A. Right upper quadrant, radiating to the right shoulder.
- B. Right upper quadrant, radiating to the left shoulder.
- C. Right lower quadrant, radiating to the pelvic bones.
- D. Right lower quadrant, radiating to the umbilicus.
Correct Answer: A
Rationale: Cholecystitis typically causes pain in the right upper quadrant radiating to the right shoulder (A) due to gallbladder inflammation and referred pain via the phrenic nerve.