Nokea
Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?
- A. Injecting 10 mL of air into the tube to facilitate drainage.
- B. Applying a water-soluble lubricant to the client's nares.
- C. Coiling extra tubing on the client's bed.
- D. Irrigating the tube with 50 mL of normal saline solution.
Correct Answer: D
Rationale: The correct answer is D because irrigating the Cantor tube with normal saline solution is inappropriate. Cantor tubes are typically used for gastric decompression or feeding, and irrigating with normal saline can disrupt the balance of electrolytes in the stomach. Choice A is correct as injecting air helps facilitate drainage. Choice B is correct as lubricant aids in tube insertion. Choice C is incorrect as coiling tubing can cause kinks and hinder drainage.
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A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the
- A. Stomach.
- B. Small intestine.
- C. Large intestine.
- D. Colon.
Correct Answer: B
Rationale: The correct answer is B: Small intestine. After a gastrectomy, where the stomach is removed or bypassed, intrinsic factor production is reduced, impacting the absorption of vitamin B12. Intrinsic factor is necessary for the absorption of B12 in the small intestine, specifically in the ileum. If vitamin B12 is not absorbed in the small intestine, it can lead to pernicious anemia. Therefore, the small intestine is crucial for the absorption of vitamin B12 in the absence of intrinsic factor. Choices A, C, and D are incorrect as the stomach, large intestine, and colon do not play a significant role in the absorption of vitamin B12.
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
- A. Yogurt
- B. Broccoli
- C. Cucumbers
- D. Eggs
Correct Answer: A
Rationale: The correct answer is A: Yogurt. Yogurt contains probiotics that help maintain a healthy balance of gut bacteria, which can reduce the odor of stool in the ostomy drainage bag. Probiotics can also improve digestion and overall gut health. Broccoli (B) and eggs (D) can actually contribute to stronger odors due to their sulfur content. Cucumbers (C) are low in fiber and may not have a significant impact on stool odor.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections.
- B. Vitamin B6 injections.
- C. An antibiotic.
- D. An antacid.
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is necessary for the absorption of vitamin B12 in the intestines. Therefore, the client with this disorder will need vitamin B12 injections to bypass the need for intrinsic factor.
Choice B (Vitamin B6 injections) is incorrect because pernicious anemia specifically involves a deficiency in vitamin B12, not B6. Choice C (An antibiotic) is incorrect as antibiotics are not indicated for pernicious anemia. Choice D (An antacid) is also incorrect as it does not address the underlying issue of vitamin B12 deficiency caused by the lack of intrinsic factor.
A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
- A. Notify the physician
- B. Document the amount and characteristics of the drainage
- C. Apply ice to the stoma site
- D. Apply pressure to the site
Correct Answer: B
Rationale: The correct answer is B: Document the amount and characteristics of the drainage. This is appropriate as serosanguineous drainage is expected after colostomy creation. Documenting helps monitor for any changes and provides crucial information for the healthcare team.
Choice A (Notify the physician) is not necessary at this point as serosanguineous drainage is normal postoperatively. Choice C (Apply ice to the stoma site) and Choice D (Apply pressure to the site) are both incorrect actions that are not indicated in this situation and could potentially harm the client.
Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
- A. Aspirating with a syringe and observing for the return of gastric contents.
- B. Irrigating with normal saline and observing for the return of solution.
- C. Placing the tube's free end in water and observing for air bubbles.
- D. Instilling air and auscultating over the epigastric area for the presence of the tube.
Correct Answer: A
Rationale: The correct answer is A: Aspirating with a syringe and observing for the return of gastric contents. This technique is used first because it directly confirms the tube's placement by withdrawing gastric contents. If the tube is in the stomach, gastric contents will be aspirated.
Choice B is incorrect because irrigating with normal saline does not confirm the tube placement in the stomach. Choice C is incorrect because placing the tube's free end in water and observing for air bubbles is not an accurate method to confirm stomach placement. Choice D is incorrect because instilling air and auscultating over the epigastric area may not provide definitive confirmation of tube placement in the stomach.