which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?

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.

2. Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?

Correct answer: D

Rationale: Monitoring for symptoms of hemorrhage is a crucial part of the immediate postoperative management of a client who has undergone gastric resection.

3. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

Correct answer: B

Rationale: Severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output in a patient with ulcerative colitis may indicate bowel perforation.

4. 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?

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.

5. You have a patient with achalasia (incomplete muscle relaxation of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer?

Correct answer: A

Rationale: Isosorbide dinitrate (Isordil) is a medication used to relax the muscles of the GI tract in patients with achalasia.

Similar Questions

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You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:
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