Nokea
You are caring for a client who is in the burn unit with severe burns. Since this is your first client contact with this person, you introduce yourself and tell the client that they will be taken care of by you for this shift. The client greets you and states, 'Why am I getting this stuff that is hanging up here?' as they are pointing to the ordered total parenteral infusion. You should:
- A. Respond to the client stating, 'I don't think you should be getting this. I am going to call your doctor.'
- B. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired as the result of your burns'.
- C. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired because you aren't eating enough.'
- D. Respond to the client stating, 'I don't think you should be getting this. I am going to turn it off now.'
Correct Answer: B
Rationale: TPN (B) is used in burn patients to meet high nutritional demands when oral intake is insufficient due to metabolic stress from burns, not just lack of eating (C). Options A and D are inappropriate as they suggest stopping or questioning a valid treatment.
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Which of the following interventions is helpful in reducing the effects of Gastroesophageal Reflux Disease (GERD)?
- A. Lie down after eating.
- B. Wear a girdle.
- C. Elevate the head of the bed on 4-6 inch blocks.
- D. Increase fluid intake just before bedtime.
Correct Answer: C
Rationale: Elevating the head of the bed (C) reduces GERD symptoms by preventing acid reflux during sleep. Lying down (A), wearing a girdle (B), or increasing fluids at bedtime (D) worsen reflux.
The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. This action is appropriate and does not require follow-up. The nurse understands that the primary purpose of placing this tube is to
- A. Feed the client.
- B. Decompress the stomach.
- C. Irrigate the stomach.
- D. Administer medications.
Correct Answer: B
Rationale: A nasogastric tube in paralytic ileus (B) decompresses the stomach, relieving distention and preventing complications like aspiration.
The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.
The nurse is caring for a client who is diagnosed with acute appendicitis. After several hours of pain, the client suddenly states a relief in his pain. What is the initial action of the nurse?
- A. Notify the physician
- B. Document the finding
- C. Insert an IV cannula
- D. Administer a laxative
Correct Answer: A
Rationale: Sudden pain relief in appendicitis (A) may indicate appendix rupture, a medical emergency requiring immediate physician notification.
The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
- A. Iron sucrose
- B. Enoxaparin
- C. Sucralfate
- D. Hydroxyurea
Correct Answer: B
Rationale: Enoxaparin, an anticoagulant, increases bleeding risk, which is concerning in a client with occult blood in the stool. Iron sucrose treats anemia, sucralfate protects the gastric mucosa, and hydroxyurea is not directly related to gastrointestinal bleeding.