Nokea
The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. This action is appropriate and does not require follow-up. The nurse understands that the primary purpose of placing this tube is to
- A. Feed the client.
- B. Decompress the stomach.
- C. Irrigate the stomach.
- D. Administer medications.
Correct Answer: B
Rationale: A nasogastric tube in paralytic ileus (B) decompresses the stomach, relieving distention and preventing complications like aspiration.
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The nurse is developing a teaching plan for a client with post-gastrectomy dumping syndrome. Which of the following statements should the nurse make to the client?
- A. Take small sips of water during meals to soften the food for easier digestion.
- B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery.
- C. Plan rest periods of 10 minutes after every meal.
- D. Meals should consist of dry foods with low carbohydrates, moderate fat, and high protein content.
Correct Answer: D
Rationale: Dry, low-carbohydrate, moderate-fat, high-protein meals (D) slow gastric emptying, reducing dumping syndrome symptoms. Sips during meals (A), expecting resolution in 4-6 weeks (B), or short rest periods (C) are incorrect.
The nurse is caring for a client with appendicitis experiencing pain. Which pain relief method would be inappropriate for this client?
- A. Applying ice packs to the abdomen
- B. Practicing breathing exercises with the patient
- C. Using a heating pad on the abdomen
- D. Encouraging rest
Correct Answer: C
Rationale: Using a heating pad on the abdomen is inappropriate for a client with appendicitis as it may increase inflammation or risk perforation of the appendix. Ice packs, breathing exercises, and rest are safer and more appropriate for pain management.
The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
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.
The nurse is caring for an undernourished client who recently began receiving total parenteral nutrition (TPN). Which laboratory value would indicate that the client is responding to treatment?
- A. Fasting blood glucose: 129 mg/dL (7.15 mmol/L) [70-110 mg/dL, 4.0–6.0 mmol/L]
- B. White blood cell (WBC) count: 12,000 mm3 (0.012×10⁹/L) [4,000-11,000 cells/µL,3.5–10.5 × 10⁹/L]
- C. Albumin: 3.6 g/dL [3.5-5 g/dL]
- D. Urine specific gravity: 1.040 [1.005-1.030]
Correct Answer: C
Rationale: Albumin within the normal range (3.6 g/dL) indicates improved nutritional status, a goal of TPN. Elevated glucose, WBC, and urine specific gravity suggest other issues (e.g., hyperglycemia, infection, dehydration) not directly related to TPN’s therapeutic effect.