Nursing Elites

1. The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?

• A. Restricting pain medication
• B. Maintaining bedrest
• C. Avoiding coughing
• D. Irrigating the drain

Correct answer: C

Rationale: Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.

2. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

• A. Notify the doctor immediately.
• B. Stop the feeding, and clamp the NG tube.
• C. Discard the 220ml, and clamp the NG tube.
• D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

Correct answer: B

Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.

3. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

• A. You’ll need to turn from side to side every 2 hours.
• B. It’s always a good idea to rest quietly after surgery.
• C. The doctor will probably order you to lie flat for 24 hours.
• D. Why don’t you decide about activity after you return from the recovery room?

Correct answer: A

Rationale: The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.

4. A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?

• A. Half-inch or one-inch tape
• B. Oil-soluble lubricant
• C. A glass of tap water with a straw
• D. A 50-mL catheter tip syringe

Correct answer: B

Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

5. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

• A. He has fresh, active upper GI bleeding.
• B. He needs immediate saline gastric lavage.
• C. His gastric bleeding occurred 2 hours earlier.
• D. He needs a transfusion of packed RBCs.

Correct answer: C

Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.

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