<P> client is to receive gavage feeding through a nasogastric (NG) tube.

Which
<Q>A
<TYPE>single</TYPE>
of the following nursing actions should be instituted to prevent complications?<
<MC1>Flushthe
/Q>
<MC2>Place
<MC3>Advance
<MC4>Plug
<F>Rationale:
<CORRECT>2</CORRECT>
with
client
tube
air20vent
Keeping
1inmLcm</MC3>
high
ofduring
the air</MC1>
Fowler's
clientfeeding</MC4>
inposition</MC2>
a high Fowler's position minimizes the risk
of aspiration (option 2). Flushing with air (option 1) will increase abdominal d
istention and increase discomfort as well as the risk for aspiration. Advancing
the tube (option 3) is only relevant if it is a nasoduodenal tube that has not a
dvancedNeed:
Cognitive
Client
Integrated
Content
Strategy: beyond
Area:
Level:
Focus
Process:
Physiological
Fundamentals
the
onApplication
pylorus.
the
Nursing
factIntegrity:
Plugging
Process:
that the NGthe
Implementation
Physiological
tube
air bypasses
vent (option
Adaptation
the oropharynx
4) is unnecessary.
and the gag
reflux. This fact then leads you to the conclusion that the airway is compromis
ed. Select Berman,
Reference: the distracter
A., Snyder,that S.,protects
Kozier,theB.,
airway.
& Erb, G. (2008). <i>Fundamentals
of nursing: concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>A
<TYPE>single</TYPE>
<P>
</P> client isEducation,
to have an pp.intestinal
1266-1267.</F>tube placed to decompress the bowel. Which
of the following explanations should the nurse give to the client about what to
<MC1>"You will
expect?</Q>
<MC2>"While theneed
tubetoisremainin place,on bedrest
you willuntil
needthe
to lie
tubeonly
is removed."</MC1>
on your right side."
<MC3>"Walking Activity,
</MC2>
<MC4>"Keeping
<F>Rationale:
<CORRECT>3</CORRECT>
in the
the bedhallflat
including
will
shouldhelpposition
make
moveyouthechanges
more
tubecomfortable."</MC4>
forward."</MC3>
and ambulation (option 3), st
imulate intestinal peristalsis and assist in the forward movement of the tube, r
uling out bedrest (option 1) or lying flat (option 4). Although it is helpful to
lie on the right side to help the tube advance past the pyloric sphincter, lyin
g only Need:
Cognitive
Client
Integrated
Content
Strategy:
onArea:
the
Level:
Recall
Process:
Physiological
right
Fundamentals
Application
that side
Nursing
thewill
nasointestinal
Integrity:
Process:
delay the Implementation
Physiological
advancement
tube needs toof advance
Adaptation
the tubethrough
(optionthe
2).intes
tine via peristalsis. Select the distracter that increases peristalsis and aids
tube passage.
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 813.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is caring for a client with a Sengstaken-Blakemore tube. Which of t
he following actions should the nurse take first if the client suddenly experien
ces difficulty
<MC1>Elevate
<MC2>Apply
<MC3>Listen
<MC4>Cut
<F>Rationale:
<CORRECT>4</CORRECT>
andoxygen
toremove
head
Respiratory
breathing?</Q>
the ofclient's
withthe
theatube</MC4>
bed</MC1>
nasal
distress
lungs</MC3>
cannula</MC2>
is an indication that the Blakemore tube has
migrated upward into the oropharynx and is obstructing the airway. The tube shou
ld be cut if the client experiences respiratory compromise (option 4). For this
reason, scissors should be kept at the bedside of all clients with an esophagoga
stric tube. The other selections (options 1, 2, and 3) will be ineffective as lo
ng as the
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Sengstaken-Blakemore
Level:
Always
Process:
Physiological
AdultAnalysis
provide
Nursing
Health: anIntegrity:
Process:
Gastrointestinal
opentube
airway.
isImplementation
Physiological
obstructing
In this case,
the
Adaptation
airway.
the Blakemore tube must b
e removed toLeMone,
Reference: open the P.,airway.
& Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 719.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> client returns to the nursing unit postoperatively after a colostomy. Whi
ch of the following
<MC1>Stoma
<MC2>Stoma
<MC3>Stoma
<MC4>Stoma
<F>Rationale:
<CORRECT>2</CORRECT>
is Adraining
bright
bluish</MC2>
healthy assessments
red</MC1>
serous
no
stoma
fluid</MC4>
fluid</MC3>
is would
red torequire
reddish-pink,
immediatemoist,
actionandbyshiny
the nurse?</Q>
(option 1
). A stoma that appears dark red, bluish, or black indicates ischemia or necrosi
s (option 2). This finding must be reported immediately because the viability of
the tissue is at risk. The colostomy is not functional for 2 to 4 days. No drai
nage (option 4) or serous fluid (option 3) is a normal finding in the immediate
postoperative
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
Physiological
period.
Adult
stomaApplication
Nursing
Health:
is liveIntegrity:
Process:andAssessment
Gastrointestinal
tissue Physiological
should resemble Adaptation
normal bowel. Any stoma d
eprived of oxygen will take on the characteristics of all tissues with an inadeq
uate oxygenLeMone,
Reference: supply.P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 804-806.</F>
is caring for a client with a Minnesota tube in place for bleeding
esophageal varices. After change of shift report, the nurse goes in to assess th
e client. The client is dyspneic with a respiratory rate of 28 and an oxygen sat
uration of 90%. What actions should the nurse take immediately? Select all that
<MC1>CallMinnesota
apply.</Q>
<MC2>Deflate
<MC3>Cut
<MC4>Apply
<MC5>Place
<F>Rationale:
<CORRECT>[3,4,5]</CORRECT>
rapid
low-flow
client
gastric
Theresponse
intube
immediate
oxygen
aandhigh
and
team
esophageal
atconcern
remove
fowler's
2toliters
intubate
it</MC3>
balloons
with
position</MC5>
asaallowed
client</MC1>
Seng-staken-Blakemore
and remove
by a PRN
theoxygen
tube</MC2>
ororder</MC4>
Minnesota tu
be is that the tube will migrate up into the oropharynx and suffocate the client
. If the client exhibits sudden acute respiratory distress, the immediate respon
se is to cut the tube (option 3) so the air is expelled from the balloons and th
en remove the tube. This immediately reopens the airway. All clients with a Minn
esota or Sengstaken-Blakemore should have scissors taped to the head of the bed
for this reason. The use of oxygen and positioning to assist in breathing (optio
ns 4 and 5) should be done also once the balloon is removed. Time should not be
wasted deflating the tube (option 2) and the rapid response team is not necessar
y at this
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
time
Level:
Recognize
Process:
Physiological
Adult
(option
Analysis
Nursing
Health:
that 1).theIntegrity:
Process:
Gastrointestinal
immediateImplementation
Reduction
priority is of to
Riskrescue
Potential
the client's airway
. Use the process of elimination knowing complications of this tube to select di
stracters that will immediately open the airway and relieve the respiratory dist
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
ress.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 719.</F>is admitted to the hospital in a malnourished state. The nurse under
stands the client is at a high risk for which of the following conditions as a r
esult of decreased
<MC4>Tumor
<MC3>Fever</MC3>
<MC2>Diarrhea</MC2>
<MC1>Infection</MC1>
<F>Rationale:
<CORRECT>1</CORRECT>
formation</MC4>
Undernutrition
nutrition?</Q>
affects many systems, causing decreases in metaboli
c function and cell-mediated and humoral immunity, thereby increasing the suscep
tibility to infection (option 1). The client with malabsorption may have fat-lad
en diarrhea stools (option 2) as a presenting symptom. Fever (option 3) indicate
s that an infection is already present. Tumor formation may be a cause of malabs
orptionNeed:
Cognitive
Client
Integrated
Content
Strategy:syndrome
Area:
Level:
Adequate
Process:
Physiological
Adult
butnutrition
Analysis
Nursing
Health:
does notIntegrity:
Process:
Immunologic
isoccur
needed asAnalysis
Physiological
a result
for all activities
of itAdaptation
(option
of the
4).human body. Eli
minate distracters that are symptoms of a problem. Select the distracter that ha
s the broadest
Reference: LeMone,
view.P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 641-642.</F>
with gastroesophageal reflux disease (GERD) is prescribed famotidi
ne (Pepcid). In order to provide effective teaching, the nurse must include whic
h information
<MC1>It
<MC2>It
<MC3>It
<MC4>It
<F>Rationale:
<CORRECT>4</CORRECT>
improves
coats
increase
decreases
about
the
Famotidine
gastric
the
distal
thethe
gastric
secretion
action
motility</MC1>
portion
is apH</MC3>
histamine-2
ofofofthe
gastric
thedrug?</Q>
esophagus</MC2>
receptor
acid</MC4>
antagonist and reduces the se
cretion of gastric acid (option 4). This class of drugs does not have a direct e
ffect on reflux, LES tone, or GI motility. Metoclopramide improves GI motility (
option 1). Sucralfate coats the ulcer (option 2). Antacids neutralize the hydroc
hloric Need:
Cognitive
Client
Integrated
Content
Strategy:
acid
Area:
Level:
List
Process:
inPhysiological
Adult
theApplication
stomach
medications
NursingIntegrity:
Health: (option
Process:
Gastrointestinal
commonly3).Planning
Pharmacological
used in GERD andandtheir
Parenteral
mechanisms
Therapies
of act
ion. Compare this information to each of the distracters until the action of fam
otidine is LeMone,
Reference: identified.P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 678.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse should question the client with gastroesophageal reflux disease (GE
RD) about the use of which type of medications that decrease lower esophageal sp
hincter (LES)channel
<MC2>Calcium
<MC1>Antidepressants</MC1>
<MC3>Antiestrogen
<MC4>Alpha-adrenergic
<F>Rationale:
<CORRECT>3</CORRECT>
tone?</Q>
Many agents</MC3>
common
blockers</MC2>
blocking
substances
agents</MC4>
contribute to decreased LES tone including
fatty foods, caffeinated beverages, nicotine, beta-adrenergic blocking agents, c
alcium channel blockers (option 2), nitrates, theophylline, peppermint, alcohol,
high levels of estrogen and progesterone, and anticholinergic drugs. Antidepres
sants, antiestrogen agents, and alpha adrenergic blockers have no effect on LES
Cognitive
tone.
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Identify
Process:
Physiological
Adult
Application
how
Nursing
Health:
the lower
Integrity:
Process:
Gastrointestinal
esophageal
Implementation
Pharmacological
sphincter contributes
and Parenteral
to the
Therapies
symptom
s of GERD. LeMone,
Reference: Select the P.,drug
& Burke,
that K.increases
(2008).that
<i>Medical-surgical
effect. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. client
<Q>The
<TYPE>single</TYPE>
<P>
</P> 666-667.</F>
with irritable bowel syndrome (IBS) asks the nurse what causes the
disease. Which of the following responses by the nurse would be most appropriat
<MC1>"This is an inflammation of the bowel caused by eating too much roughage."<
e?</Q>
<MC2>"IBS cause
/MC1>
<MC3>"The
<MC4>"Thereisiscaused
thinning
of this
by aof
condition
stressful
the intestinal
islifestyle."</MC2>
unknown."</MC3>
mucosa caused by ingestion of gluten."
<F>Rationale: There is no known cause of IBS, and diagnosis is made by excluding
<CORRECT>3</CORRECT>
</MC4>
all the other diseases that cause the symptoms (option 3). There is no inflamma
tion of the bowel (option 1). Some factors exacerbate the symptoms (option 2), i
ncluding anxiety, fear, stress, depression, some foods (options 1 and 4) and dru
gs, butNeed:
Cognitive
Client
Integrated
Content
Strategy:these
Area:
Level:
Differentiate
Process:
Physiological
do Application
Adult
notHealth:
Nursing
cause
theIntegrity:
the
Process:
Gastrointestinal
different
disease. Assessment
Physiological
forms of inflammatory
Adaptation
bowel disease and ca
usative factors
References: LeMone,
versusP.,exacerbating
& Burke, K. (2008).
factors.<i>Medical-surgical nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 762.</F>
with Crohn's disease (regional enteritis) who is taking sulfasalazin
e (Azulfidine) asks the nurse why this medication is necessary. Which informatio
n should drug
<MC1>The
<MC2>The the nurse
decreases
include
abdominal
prostaglandin
in the cramping
response?</Q>
production
by slowing
in theperistalsis.</MC1>
bowel so it decreases in
<MC3>The drug Sulfasalazine
flammation.</MC2>
<MC4>The
<F>Rationale:
<CORRECT>2</CORRECT>
inhibits neurotransmission
stimulates theisrelease
a GI anti-inflammatory
of endorphins
of pain impulses.</MC3>
so medication
pain is relieved.</MC4>
that exerts its
action by decreasing prostaglandin production in the bowel (option 2). Peristal
sis is decreased by anticholinergic agents (option 1). Analgesics affect pain im
pulses Need:
Cognitive
Client
Integrated
Content
Strategy:
(options
Area:
Level:
Review
Process:
Physiological
Adult
3the
Application
andHealth:
Nursing
goals
4). ofIntegrity:
Process:
Gastrointestinal
treatment Implementation
Pharmacological
for inflammatoryandbowel
Parenteral
disease.
Therapies
Select t
he distracter
Reference: LeMone,
that P.,
works& Burke,
directlyK.to(2008).decrease
<i>Medical-surgical
the inflammatory nursing:
response.Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 786-787.</F>
</P>