Nursing Elites

1. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

• A. Confirm proper nasogastric tube placement.
• B. Observe gastric contents.
• C. Assess fluid and electrolyte status.
• D. Evaluate absorption of the last feeding.

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

2. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

• A. Injecting 10 mL of air into the tube to facilitate drainage.
• B. Applying a water-soluble lubricant to the client's nares.
• C. Coiling extra tubing on the client's bed.
• D. Irrigating the tube with 50 mL of normal saline solution.

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

3. You’re patient is complaining of abdominal pain during assessment. What is your priority?

• A. Auscultate to determine changes in bowel sounds.
• B. Observe the contour of the abdomen.
• C. Palpate the abdomen for a mass.
• D. Percuss the abdomen to determine if fluid is present.

Correct answer: A

Rationale: When a patient is complaining of abdominal pain, the priority is to auscultate to determine changes in bowel sounds.

4. After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?

• A. Pain, fever, and abdominal rigidity.
• B. Diarrhea with fat in the stool.
• C. Palpitations, pallor, and diaphoresis after eating.
• D. Feelings of fullness and nausea after eating.

Correct answer: A

Rationale: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

5. Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?

• A. Obesity
• B. Volvulus
• C. Constipation
• D. Intestinal obstruction

Correct answer: B

Rationale: Obesity, constipation, and intestinal obstruction can all lead to increased abdominal pressure, which in turn can cause a hiatal hernia.

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