Nokea
The patient has come to the PACU following an ileostomy for the treatment of ulcerative colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma. What should be the nurse's initial action?
- A. Turn patient to right side.
- B. Give patient ice chips to moisten mouth.
- C. Attach NG tube to suction.
- D. Irrigate NG tube.
Correct Answer: C
Rationale: Initially, the NG tube should be attached to suction to decompress the stomach and prevent nausea. Assessing the tube for the need of future irrigation will be part of the postoperative care.
You may also like to solve these questions
What is the most lethal complication of a peptic ulcer?
- A. Bleeding
- B. Perforation
- C. Severe pain
- D. Gastric outlet obstruction
Correct Answer: B
Rationale: Perforation is considered the most lethal complication of peptic ulcer. Bleeding may occur when the ulcer erodes into a blood vessel; however, perforation occurs when the ulcer crater penetrates the entire thickness of the wall of the stomach or duodenum. Gastric outlet obstruction can occur at any time and can be relieved by NG aspiration of stomach contents.
Which will be the most helpful nursing intervention to increase the comfort of a patient with appendicitis?
- A. Applying of ice bag
- B. Administration of small tap water enema
- C. Warm compress over entire abdomen
- D. Ambulate for short periods in the room
Correct Answer: A
Rationale: Applying of an ice bag will decrease the flow of blood to the area and impede the inflammatory process.
The nurse caring for a patient with a peptic ulcer who has had a nasogastric tube inserted notes bright blood in the tube, the patient complains of pain and has become hypotensive. Which condition should the nurse recognize these as signs of?
- A. Hiatal hernia
- B. Gastritis
- C. Perforation
- D. Bowel obstruction
Correct Answer: C
Rationale: Perforation of the gastric wall causes pain, hypotension, and hematemesis. Immediate reporting to the charge nurse/physician is essential as peritonitis, potentially lethal, is the result of a perforation.
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.
The nurse clarifies that the end product of food is absorbed and put into the bloodstream by which anatomical feature?
- A. gastric lining of the stomach.
- B. villi of the small intestine.
- C. bile of the liver in the large intestine.
- D. excretion from the cecum.
Correct Answer: B
Rationale: The inner surface of the small intestine contains millions of tiny, fingerlike projections called villi, which contain small blood vessels. They are responsible for absorbing the products of digestion.