Nokea
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.
You may also like to solve these questions
A nurse is providing the client with biliary obstruction a simple overview of the anatomy of the liver and gallbladder. The nurse tells the client that normally the liver stores bile in the gallbladder, which is connected to the liver by the?
- A. Liver canaliculi
- B. Common bile duct
- C. Cystic duct
- D. Right hepatic duct.
Correct Answer: C
Rationale: The correct answer is C: Cystic duct. The cystic duct connects the gallbladder to the common bile duct, through which bile flows from the liver to the gallbladder for storage. The liver canaliculi are tiny channels within the liver where bile is produced. The common bile duct is the main duct through which bile flows from the liver to the small intestine. The right hepatic duct is one of the ducts that collect bile from the liver but does not directly connect to the gallbladder. Therefore, the cystic duct is the correct choice as it specifically links the gallbladder to the common bile duct for bile transportation.
The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?
- A. The family's ability to take care of the client's special diet needs
- B. The family's expectation that the client will resume responsibilities and role-related activities
- C. Emotional support from the family
- D. The family's ability to understand the ups and downs of the illness
Correct Answer: C
Rationale: The correct answer is C because emotional support from the family is crucial for the client's rehabilitation. Emotional support can positively impact the client's mental health, motivation, and adherence to treatment plans. It can also reduce stress and anxiety, which are common in chronic illnesses like ulcerative colitis. Options A and D focus on practical aspects and understanding of the illness, which are important but not as impactful as emotional support. Option B addresses the client's responsibilities, which, while important, may not have as direct an impact on rehabilitation as emotional support.
A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
- A. Place a sandbag over the insertion site.
- B. Allow the client bathroom privileges only.
- C. Encourage fluid intake.
- D. Allow the client to sit in a chair for meals.
Correct Answer: A
Rationale: The correct answer is A: Place a sandbag over the insertion site. This intervention helps maintain pressure on the puncture site, reducing the risk of bleeding or hematoma formation post-procedure. Placing a sandbag over the insertion site is a standard practice to ensure hemostasis and prevent complications.
Explanation for incorrect choices:
B: Allowing bathroom privileges only is unrelated to the specific care needs following a percutaneous transhepatic cholangiogram.
C: Encouraging fluid intake is a general nursing intervention and does not directly address the postprocedure care requirements for this specific procedure.
D: Allowing the client to sit in a chair for meals is not a priority post-procedure and does not address the potential complications associated with the puncture site.
A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?
- A. Decreased erythrocyte sedimentation rate
- B. Elevated serum bilirubin
- C. Elevated hemoglobin
- D. Elevated blood urea nitrogen
Correct Answer: B
Rationale: The correct answer is B: Elevated serum bilirubin. Hepatitis is characterized by liver inflammation, which can lead to impaired bilirubin metabolism and increased levels in the blood. Elevated serum bilirubin is a common finding in hepatitis. Decreased erythrocyte sedimentation rate (Choice A) is not specific to hepatitis. Elevated hemoglobin (Choice C) and elevated blood urea nitrogen (Choice D) are not typically associated with hepatitis and are more indicative of other conditions. In summary, elevated serum bilirubin is a key diagnostic marker for confirming a diagnosis of hepatitis.
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.