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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.
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A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
- A. Absence of nausea and vomiting.
- B. Passage of mucus from the rectum.
- C. Passage of flatus and feces from the colostomy.
- D. Absence of stomach drainage for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Passage of flatus and feces from the colostomy. This indicates that the gastrointestinal tract is functioning properly post-operatively. The nasogastric tube is typically removed once the client's bowel function has returned, as evidenced by the passage of flatus and feces from the colostomy. This indicates that the client's bowels are working and there is no longer a need for the tube to decompress the stomach. Choices A, B, and D are incorrect because the absence of nausea and vomiting, passage of mucus from the rectum, and absence of stomach drainage do not directly indicate the return of normal bowel function, which is the key factor for removing the nasogastric tube in this scenario.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?
- A. Lie down after meals to promote digestion.
- B. Avoid coffee and alcoholic beverages.
- C. Take antacids before meals.
- D. Limit fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: Avoid coffee and alcoholic beverages. This is because both coffee and alcohol can relax the lower esophageal sphincter, leading to increased risk of gastroesophageal reflux in clients with hiatal hernia.
A: Lying down after meals can actually worsen reflux symptoms by allowing stomach acid to flow back into the esophagus.
C: Taking antacids before meals may provide temporary relief but does not address the underlying cause of reflux.
D: Limiting fluids with meals can help reduce reflux by not distending the stomach, but it is not as crucial as avoiding coffee and alcohol.
A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct Answer: B
Rationale: The correct answer is B: Oil-soluble lubricant. The rationale is that oil-based lubricants should not be used for nasogastric tube insertion due to the risk of aspiration pneumonia. The other options are appropriate for the procedure: A) Tape is used to secure the tube, C) Water with a straw is used to check tube placement, and D) A syringe is used for verification of tube placement and administration of medications. Therefore, selecting B indicates a lack of understanding of proper supplies for nasogastric tube insertion.
The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?
- A. Carbohydrate
- B. Protein
- C. Fat
- D. Water-soluble vitamins
Correct Answer: C
Rationale: The correct answer is C: Fat. In chronic pancreatitis, the pancreas struggles to produce digestive enzymes, leading to poor fat digestion. Limiting fat intake can help reduce symptoms like abdominal pain and diarrhea. Carbohydrates and proteins are essential for energy and tissue repair, so limiting them is not ideal. Water-soluble vitamins are generally well-absorbed and do not require restriction in chronic pancreatitis.
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.