Nursing Elites

1. A client with rectal cancer may exhibit which of the following symptoms?

• A. Abdominal fullness
• B. Gastric fullness
• C. Rectal bleeding
• D. Right upper quadrant pain

Correct answer: C

Rationale: Rectal bleeding is a common symptom in clients with rectal cancer.

2. 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.

3. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure because of which change that is associated with the liver failure?

• A. Hypoalbuminemia
• B. Increased capillary permeability
• C. Abnormal peripheral vasodilation
• D. Excess rennin release from the kidneys

Correct answer: C

Rationale: Abnormal peripheral vasodilation is a change associated with liver failure that requires close monitoring of the patient's blood pressure.

4. A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the

• A. Stomach.
• B. Small intestine.
• C. Large intestine.
• D. Colon.

Correct answer: B

Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. Vitamin B12 is not absorbed in the large intestine (options 3 and 4).

5. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:

• A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
• B. After insertion into the nostril, instruct the client to extend his neck
• C. Introduce the tube with the client’s head tilted back, then instruct him to keep his head upright for final insertion
• D. Instruct the client to hold his chin down, then back for insertion of the tube

Correct answer: A

Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.

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