Nursing Elites

1. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

• A. Swelling of the abdomen
• B. Bloody diarrhea
• C. Vomiting blood
• D. An elevated temperature and arise in blood pressure

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

2. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

• A. Notify the physician
• B. Increase the height of the irrigation
• C. Stop the irrigation temporarily.
• D. Medicate with dilaudid and resume the irrigation

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

3. 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 initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. One would not irrigate until tube placement is confirmed. Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement.

4. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?

• A. Give diazepam in the I.V. port closest to the vein.
• B. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
• C. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
• D. Question the order because I.V. administration of diazepam is contraindicated.

Correct answer: A

Rationale: The correct method for administering I.V. diazepam is to give it in the I.V. port closest to the vein.

5. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color?

• A. Brown.
• B. Clear.
• C. Red.
• D. Yellow.

Correct answer: C

Rationale: During the immediate postoperative period after a partial gastrectomy, gastric secretions are expected to be red.

Similar Questions