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The patient with a new ileostomy needs discharge teaching. What should the nurse plan to include in this teaching?
- A. The pouch can be worn for up to 2 weeks before changing it.
- B. Decrease the amount of fluid intake to decrease the amount of drainage.
- C. The pouch can be removed when bowel movements have been regulated.
- D. If leakage occurs, promptly remove the pouch, clean the skin, and apply a new pouch.
Correct Answer: D
Rationale: The correct answer is D because in the event of leakage from the pouch, it is important to promptly remove it, clean the skin, and apply a new pouch to prevent skin irritation and infection. This step is crucial for maintaining skin integrity and preventing complications.
Choice A is incorrect as ileostomy pouches typically need to be changed more frequently, usually every 3-7 days, to prevent skin breakdown and odor.
Choice B is incorrect because decreasing fluid intake can lead to dehydration and electrolyte imbalances, which are especially risky for ileostomy patients who have increased fluid losses.
Choice C is incorrect because the pouch should not be removed until the stoma and bowel movements have been evaluated and regulated to ensure proper functioning.
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The muscular contractions, which move material through the digestive tract, are called:
- A. peristalsis
- B. deglutition.
- C. mass movements.
- D. segmental contractions.
Correct Answer: A
Rationale: The correct answer is A: peristalsis. Peristalsis refers to the wave-like muscular contractions that propel food through the digestive tract. First, circular muscles contract behind the food bolus creating a narrowing, then longitudinal muscles contract ahead of the bolus, pushing it forward. This coordinated movement helps move food along the digestive tract efficiently. Deglutition (B) refers to the act of swallowing, not the movement of food through the digestive tract. Mass movements (C) refer to large, powerful contractions that occur in the colon to move feces. Segmental contractions (D) are localized contractions that mix and churn food in the intestines, not the primary mechanism for moving food along the digestive tract.
What role do the teeth play in digestion?
- A. chemical digestion
- B. mechanical digestion
- C. enzymatic digestion
- D. absorption
Correct Answer: B
Rationale: The correct answer is B: mechanical digestion. Teeth play a crucial role in breaking down food into smaller pieces through physical chewing, which is a form of mechanical digestion. This process increases the surface area of food particles, making it easier for enzymes to further break down nutrients during chemical digestion in the stomach and intestines. Choice A (chemical digestion) is incorrect because teeth do not directly participate in chemical breakdown of food. Choice C (enzymatic digestion) is incorrect as enzymes are not produced by teeth but by salivary glands and other digestive organs. Choice D (absorption) is incorrect as teeth are not involved in absorbing nutrients; absorption primarily occurs in the small intestine.
Priority Decision: A patient is admitted to the emergency department with acute abdominal pain. What nursing intervention should the nurse implement first?
- A. Measurement of vital signs
- B. Administration of prescribed analgesics
- C. Assessment of the onset, location, intensity, duration, and character of the pain
- D. Physical assessment of the abdomen for distention, bowel sounds, and pigmentation changes
Correct Answer: C
Rationale: The correct answer is C. Assessing the onset, location, intensity, duration, and character of the pain is the priority because it helps determine the potential cause of the abdominal pain. This information guides further interventions and informs the healthcare team about the urgency of the situation.
Choice A (Measurement of vital signs) can be important but assessing the pain characteristics takes precedence as it directly informs the urgency of the situation.
Choice B (Administration of prescribed analgesics) should be delayed until the cause of the pain is identified to prevent masking symptoms that could aid in diagnosis.
Choice D (Physical assessment of the abdomen) is important but assessing the pain characteristics comes first to guide the physical assessment and subsequent interventions.
Which of the following cells in the stomach secrete pepsinogen?
- A. parietal cells
- B. chief cells
- C. mucous neck cells
- D. enteroendocrine cells
Correct Answer: B
Rationale: The correct answer is B: chief cells. Chief cells are responsible for secreting pepsinogen in the stomach. Pepsinogen is an inactive form of pepsin, which is an enzyme that helps in protein digestion. Parietal cells secrete hydrochloric acid, not pepsinogen. Mucous neck cells secrete mucus to protect the stomach lining. Enteroendocrine cells secrete hormones like gastrin, but not pepsinogen. Therefore, the correct answer is B as chief cells are the specific cells that secrete pepsinogen in the stomach.
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?
- A. Ranitidine absorbs the excess gastric acid.
- B. Ranitidine decreases gastric acid secretion.
- C. Ranitidine constricts the blood vessels near the ulcer.
- D. Ranitidine covers the ulcer with a protective material.
Correct Answer: B
Rationale: Rationale: Ranitidine is an H2 receptor antagonist that works by blocking the action of histamine on the stomach cells, thereby reducing gastric acid secretion. This helps in healing and preventing further damage to the ulcer. Option A is incorrect as ranitidine doesn't absorb excess gastric acid; it reduces its production. Option C is incorrect as ranitidine doesn't constrict blood vessels. Option D is incorrect as ranitidine doesn't cover the ulcer but rather decreases acid secretion to promote healing.