Nokea
Which patient has the highest risk for poor nutritional balance related to decreased ingestion?
- A. Tuberculosis infection
- B. Draining decubitus ulcers
- C. Malabsorption syndrome
- D. Severe anorexia resulting from radiation therapy
Correct Answer: D
Rationale: The correct answer is D: Severe anorexia resulting from radiation therapy. This patient has the highest risk for poor nutritional balance due to the severe anorexia caused by the treatment. Radiation therapy often leads to loss of appetite, making it difficult for the patient to ingest adequate nutrients, resulting in malnutrition.
A: Tuberculosis infection does not necessarily directly cause decreased ingestion, as appetite may vary among patients.
B: Draining decubitus ulcers may lead to protein and fluid loss but not necessarily decreased ingestion.
C: Malabsorption syndrome affects the absorption of nutrients but does not directly relate to decreased ingestion.
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A patient comes to the hospital complaining of vomiting and diarrhoea. The doctor suggested that the patient take glucose and electrolyte solution orally. Which one of following membrane proteins is likely to be involved in rehydrating the patient?
- A. Cystic fibrosis transmembrane regulator (CFTR)
- B. Sodium glucose transporter protein! (SGLT1)
- C. Insulin receptor protein (IRP)
- D. Sucrase-isomaltase protein (SIP)
Correct Answer: B
Rationale: The correct answer is B: Sodium glucose transporter protein 1 (SGLT1). SGLT1 is responsible for the active transport of glucose and sodium across the intestinal membrane. When a patient is experiencing vomiting and diarrhea, they are losing fluids and electrolytes. By taking a glucose and electrolyte solution orally, the SGLT1 protein helps in the reabsorption of glucose and sodium to facilitate rehydration.
Incorrect choices:
A: Cystic fibrosis transmembrane regulator (CFTR) is associated with cystic fibrosis and does not play a direct role in rehydration.
C: Insulin receptor protein (IRP) is involved in glucose uptake regulation in response to insulin, not rehydration.
D: Sucrase-isomaltase protein (SIP) is involved in the breakdown of sugars in the small intestine, not rehydration.
On examining a patient 8 hours after having surgery to create a colostomy, what should the nurse expect to find?
- A. Hyperactive, high-pitched bowel sounds
- B. A brick-red, puffy stoma that oozes blood
- C. A purplish stoma, shiny and moist with mucus
- D. A small amount of liquid fecal drainage from the stoma
Correct Answer: C
Rationale: The correct answer is C because 8 hours post colostomy surgery, a purplish stoma that is shiny and moist with mucus indicates adequate blood supply and tissue perfusion, which are signs of a healthy stoma. A is incorrect as hyperactive, high-pitched bowel sounds are not expected immediately post-surgery. B is incorrect as a brick-red, puffy stoma oozing blood could indicate poor perfusion. D is incorrect as liquid fecal drainage is not expected immediately post-surgery; it usually starts a few days later.
Which of the following hydrolytic enzymes act in low pH?
- A. Peroxidases
- B. Hydrolases
- C. Amylases
- D. Proteases
Correct Answer: D
Rationale: The correct answer is D: Proteases. Proteases are enzymes that break down proteins, and they are known to function optimally in low pH environments, such as the acidic environment of the stomach. This is because the acidic pH helps in the activation and stability of proteases, allowing them to efficiently break down proteins into smaller peptides and amino acids.
Rationale for why the other choices are incorrect:
A: Peroxidases catalyze oxidation reactions and are not specifically known to act in low pH environments.
B: Hydrolases are a broad category of enzymes that catalyze the hydrolysis of various molecules but are not specifically tailored for low pH conditions.
C: Amylases are enzymes that break down carbohydrates and typically work best in neutral to slightly alkaline pH conditions, not in low pH environments like proteases.
What is a postoperative nursing intervention for the obese patient who has undergone bariatric surgery?
- A. Irrigating and repositioning the nasogastric (NG) tube as needed
- B. Delaying ambulation until the patient has enough strength to support self
- C. Keeping the patient positioned on the side to facilitate respiratory function
- D. Providing adequate support to the incision during coughing, deep breathing, and turning
Correct Answer: D
Rationale: The correct answer is D because providing adequate support to the incision during coughing, deep breathing, and turning is essential postoperatively to prevent complications such as wound dehiscence or infection in obese patients who have undergone bariatric surgery. Supporting the incision helps reduce stress on the surgical site and promotes proper healing.
Choice A is incorrect because irrigating and repositioning the nasogastric tube is not a specific nursing intervention related to the care of the incision after bariatric surgery.
Choice B is incorrect because delaying ambulation can increase the risk of complications such as deep vein thrombosis and pneumonia in postoperative obese patients.
Choice C is incorrect because keeping the patient positioned on the side to facilitate respiratory function is important, but it is not directly related to supporting the incision during activities that increase intra-abdominal pressure.
Care for which of these clients is most appropriate to assign to the LPN/LVN, under the supervision of an RN?
- A. A client with oral cancer who is scheduled in the morning for glossectomy
- B. An obese client returned from surgery following a vertical banded gastroplasty
- C. A client with anorexia nervosa with muscle weakness and decreased urine output
- D. A client with intractable nausea and vomiting related to chemotherapy
Correct Answer: D
Rationale: The correct answer is D because the LPN/LVN can provide care for a client with intractable nausea and vomiting related to chemotherapy under the supervision of an RN. The LPN/LVN can administer prescribed antiemetic medications, monitor the client's response, assess for dehydration, and provide comfort measures. This task falls within the scope of practice for an LPN/LVN and does not require the advanced assessment and intervention skills of an RN.
Choice A is incorrect because a client undergoing a glossectomy for oral cancer requires complex post-operative care that is beyond the scope of practice for an LPN/LVN.
Choice B is incorrect because post-operative care for an obese client following a vertical banded gastroplasty involves monitoring for complications such as leaks or infections, which require the expertise of an RN.
Choice C is incorrect because a client with anorexia nervosa with muscle weakness and decreased urine output may have underlying medical issues that require an RN's assessment and intervention skills