Nursing Elites

1. 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.

2. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

• A. Absence of nausea and vomiting.
• B. Passage of mucus from the rectum.
• C. Passage of flatus and feces from the colostomy.
• D. Absence of stomach drainage for 24 hours.

Correct answer: C

Rationale: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued.

3. A patient has a severe exacerbation of ulcerative colitis. Long-term medications will probably include:

• A. Antacids.
• B. Antibiotics.
• C. Corticosteroids.
• D. Histamine2-receptor blockers.

Correct answer: C

Rationale: Long-term medications for a severe exacerbation of ulcerative colitis probably include corticosteroids.

4. To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?

• A. Nail beds
• B. Skin on the back of the hand
• C. Hard palate of the mouth
• D. Soles of the feet

Correct answer: C

Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.

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.

Similar Questions