Nokea
Where are most fat-digesting enzymes produced?
- A. small intestine
- B. gallbladder
- C. liver
- D. pancreas
Correct Answer: D
Rationale: The correct answer is D: pancreas. The pancreas produces most fat-digesting enzymes, such as lipase, which help break down fats in the small intestine. The liver produces bile, stored in the gallbladder, which aids in fat digestion but doesn't directly produce fat-digesting enzymes. The small intestine primarily absorbs nutrients rather than producing fat-digesting enzymes. Therefore, the pancreas is the main source of fat-digesting enzymes in the digestive system.
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Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome? (Select all that apply.)
- A. Weight
- B. Waist size
- C. Blood glucose
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Waist size. The nurse can confirm metabolic syndrome by assessing waist size as it is a key component in diagnosing the condition. Metabolic syndrome is characterized by central obesity, which is reflected in an increased waist circumference. The other choices, weight (A), blood glucose (C), and blood pressure (D), may provide valuable information in assessing the patient's overall health but are not specific indicators of metabolic syndrome. Weight alone does not necessarily indicate central obesity, blood glucose may be elevated due to other reasons, and blood pressure can be affected by various factors unrelated to metabolic syndrome. Therefore, waist size is the most relevant measure to confirm the presence of metabolic syndrome in this case.
A patient with inflammatory bowel disease has a nursing diagnosis of imbalanced nutrition: less than body requirements related to decreased nutritional intake and decreased intestinal absorption. Which assessment data support this nursing diagnosis?
- A. Pallor and hair loss
- B. Frequent diarrhea stools
- C. Anorectal excoriation and pain
- D. Hypotension and urine output below 30 mL/hr
Correct Answer: A
Rationale: Pallor and hair loss indicate potential nutritional deficiencies, supporting the nursing diagnosis of imbalanced nutrition due to decreased intake and absorption.
The most common cause of upper gastrointestinal hemorrhage (hematemesis or melena) is:
- A. esophageal varices
- B. gastric carcinoma
- C. peptic ulcer
- D. gastritis
Correct Answer: C
Rationale: The correct answer is C: peptic ulcer. Peptic ulcers are a common cause of upper gastrointestinal hemorrhage due to erosion of the stomach lining. The acidic environment in the stomach can lead to ulcer formation. Esophageal varices are associated with liver cirrhosis, not a common cause of hemorrhage. Gastric carcinoma may cause bleeding but is less common than peptic ulcers. Gastritis is inflammation of the stomach lining and can cause bleeding but is not as common as peptic ulcers.
A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding?
- A. Abdominal distention and rigidity
- B. NG tube intentionally displaced by client
- C. Absent or hypoactive bowel sounds
- D. Nausea and occasional vomiting
Correct Answer: A
Rationale: Abdominal rigidity and distention suggest peritonitis or internal bleeding, both of which require urgent medical intervention.
A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which intervention by the nurse is appropriate?
- A. Monitor the patient's capillary blood glucose every 6 hours.
- B. Infuse 5% dextrose in water until a new PN bag is delivere
- D. Decrease the PN infusion rate to 10 mL/hr until a new bag arrives.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Infusing 5% dextrose in water will provide the patient with necessary calories and prevent hypoglycemia until the new PN bag arrives.
2. Dextrose infusion will help maintain glucose levels and prevent metabolic complications.
3. Monitoring capillary blood glucose every 6 hours (Choice A) may not provide immediate support to prevent hypoglycemia.
4. Decreasing the PN infusion rate (Choice D) may lead to inadequate nutrition and compromise patient's metabolic needs.