College of Nursing Bulanao, Tabuk, Kalinga Philippines 3800
Nursing Care Management 103 Lecture: C. Instruction to swallow six radiopaque tablets the Midterms Quiz evening before the study. D. Positioning in a high Fowler’s position Name : immediately following the procedure. Section : Date : 4. A client complains of excessive weight loss and anorexia. Laboratory studies show that he is anemic. MULTIPLE CHOICES: Choose the correct answer. No Hepatocellular carcinoma is suspected. A liver biopsy erasures, alterations or unnecessary markings. is performed at the bedside. What intervention will be expected after the procedure? 1. An adult client has a nasogastric tube in place to A. Encourage to ambulate to prevent the formation maintain gastric decompression. Which nursing of venous thrombosis. action will relieve discomfort in the nostril with the NG B. Ask to turn, cough, and deep breathe every 2 tube? hours for the next 8 hours. A. Remove any tape and loosely pin the tube to his C. Place in a high Fowler’s position to maximize gown. thoracic expansion. B. Lubricate the NG tube with viscous xylocaine. D. Position on his right side with a pillow under the C. Loop the NG tube to avoid pressure on the costal margin, and immobile for several hours. nares. 5. A client has a fecal impaction. The physician orders D. Replace the NG tube with a smaller diameter an oil-retention enema followed by a cleansing tube. enema. What is the reason for administering an oil- 2. A client is scheduled for a esophagoduodenoscopy. retention enema to the client? In planning for the post-procedural care, what is the A. Lubricate the walls of the intestinal tract. most effective nursing action to prevent respiratory B. Soften the fecal mass and lubricate the walls of complications? the rectum and colon. A. Keep the client positioned on his left side for 8– C. Reduce bacterial content of the fecal mass. 10 hours. D. Coat the walls of the intestines to prevent B. Assess for a gag reflex before offering the client irritation by the hardened fecal mass. anything to eat or drink. 6. A client has amyotrophic lateral sclerosis. His C. Provide throat lozenges for complaints of a sore neurologic status has continued to deteriorate. He is throat. receiving enteral feedings through a gastrostomy D. Position the client in high Fowler’s until he is fully tube. What priority assessment should be performed awake and alert. before administering a bolus feeding? 3. A client is being evaluated for cancer of the colon. In A. Check the expiration date of the prepared enteral preparing the client for a barium enema, which feeding. intervention will be included that pertains to the B. Confirm the presence of a gag reflex. procedure? C. Check placement of feeding tube. A. Placement on a low-residue diet 1 to 2 days D. Review laboratory studies for indications of before the study. electrolyte imbalances. B. Given an oil retention enema the morning of the 7. An adult is 8 hours post-op a Billroth II (gastric study. resection) for an intractable gastric ulcer. The drainage from his nasogastric decompression tube is SAINT TONIS COLLEGE College of Nursing Bulanao, Tabuk, Kalinga Philippines 3800
thickened and the volume of secretions has B. Registered dietitian
dramatically reduced in the last 2 hours. The client C. Occupational therapist complains that he feels like he is going to vomit. D. Enterostomal nurse therapist What is the most appropriate nursing action? A. Reposition the nasogastric tube by advancing it -===== Good luck & God bless =====- gently. B. Notify the physician of your findings. C. Irrigate the nasogastric tube with 50 mL of sterile Prepared by: normal saline. D. Discontinue the low-intermittent suctioning. Lucky p. Roaquin, RN, LPT, MAN 8. An adult has a sigmoid colostomy. The nurse is Instructor-In-Charge performing peristomal skin care and changing the stoma pouch. What is the most appropriate nursing action? A. Empty the ostomy pouch when it is full. B. Pull flange and pouch off together to prevent spillage of stomach pouch contents. C. Leave 1⁄4 inch of skin exposed around stoma when determining size to cut new skin barrier. D. Apply liquid deodorant to mucous membrane of protruding stoma. 9. An adult has a double-barreled, transverse colostomy. The nurse has formulated the nursing diagnosis: risk for impaired skin integrity related to irritation of the peristomal skin by the effluent. What is the most appropriate nursing action relevant to this nursing diagnosis? A. Strict measurement and recording of I&O. B. Assessing for bowel sounds when changing ostomy appliance. C. Wash peristomal skin with an astringent solution to reduce bacterial contamination. D. Apply skin barrier before applying flange and ostomy pouch. 10. A patient is scheduled to have a descending colostomy. He is anxious and has many questions concerning the surgery, the care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to refer the patient to which member of the health care team? A. Social worker
