Nokea
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
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The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube?
- A. Aspiration of stomach contents
- B. pH verification of the aspirate
- C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ)
- D. Visualization on an X-ray
Correct Answer: D
Rationale: X-ray visualization (D) is the most accurate method to confirm NG tube placement, ensuring it is in the stomach and not the lungs.
The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. Pantoprazole
- B. Ciprofloxacin
- C. Lactulose
- D. Loperamide
Correct Answer: B
Rationale: Ciprofloxacin, an antibiotic, is used to treat bacterial peritonitis. Pantoprazole reduces acid, lactulose treats hepatic encephalopathy, and loperamide slows motility, none of which address peritonitis directly.
The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition?
- A. Cystic fibrosis
- B. Clostridium difficile
- C. H. pylori infection
- D. Crohn’s disease
Correct Answer: C
Rationale: Cimetidine, an H2 receptor blocker, is used in H. pylori infection to reduce gastric acid, aiding in ulcer healing alongside antibiotics. It is not indicated for cystic fibrosis, C. difficile, or Crohn’s disease.
The nurse is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include?
- A. Applying pneumatic compression devices
- B. Inserting an indwelling urinary catheter
- C. Placing the client on strict bed rest
- D. Measuring the abdominal girth
Correct Answer: A
Rationale: Pneumatic compression devices (A) prevent thromboembolism, a key risk post-bariatric surgery due to immobility and obesity. Catheters (B), bed rest (C), and girth measurement (D) are not routinely required.
The nurse is caring for a client who is postprocedure following an endoscopy. Which priority action should the nurse take prior to resuming the client's diet?
- A. Assess the client's oxygenation level
- B. Assess for the return of the client's gag reflex
- C. Have the healthcare provider speak with the client regarding results of the procedure
- D. Start with a soft diet to see if the client will tolerate
Correct Answer: B
Rationale: Assessing the gag reflex (B) ensures safe swallowing post-endoscopy to prevent aspiration before resuming the diet.