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Gastrointestinal Nursing NCLEX-PN. The nurse has an order to remove a patient’s nasogastric tube. The correct nursing action related to this procedure.

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Presentation on theme: "Gastrointestinal Nursing NCLEX-PN. The nurse has an order to remove a patient’s nasogastric tube. The correct nursing action related to this procedure."— Presentation transcript:

1 Gastrointestinal Nursing NCLEX-PN

2 The nurse has an order to remove a patient’s nasogastric tube. The correct nursing action related to this procedure would be to 1. Put on sterile gloves after untaping the tube from the patient’s face. 2. Instill 30 mL of normal saline before removing the tube. 3. Pull the tube out slowly and gently. 4. Pull the tube out quickly while keeping it pinched.

3 The nurse has an order to remove a patient’s nasogastric tube. The correct nursing action related to this procedure would be to 1. Put on sterile gloves after untaping the tube from the patient’s face. 2. Instill 30 mL of normal saline before removing the tube. 3. Pull the tube out slowly and gently. 4. Pull the tube out quickly while keeping it pinched.

4 A patient with a history of pernicious anemia has been admitted to a long- term care facility. There are no orders written. The LPN would ask the charge nurse to question the physician about obtaining medical orders for 1. Folic acid 2. Iron 3. Vitamin B6 4. Vitamin B12

5 A patient with a history of pernicious anemia has been admitted to a long- term care facility. There are no orders written. The LPN would ask the charge nurse to question the physician about obtaining medical orders for 1. Folic acid 2. Iron 3. Vitamin B6 4. Vitamin B12

6 The nurse knows there is a need for further teaching when the patient taking Coumadin says 1. “I cannot eat food high in vitamin K, such as leafy vegetables.” 2. “I can take aspirin for my ‘aches and pains’.” 3. “I need to have a prothrombin time before I return to the doctor.” 4. “I need to report any bleeding to the doctor.”

7 The nurse knows there is a need for further teaching when the patient taking Coumadin says 1. “I cannot eat food high in vitamin K, such as leafy vegetables.” 2. “I can take aspirin for my ‘aches and pains’.” 3. “I need to have a prothrombin time before I return to the doctor.” 4. “I need to report any bleeding to the doctor.”

8 A patient is started on ASA therapy. She tells the nurse that she is having a great deal of gastrointestinal distress. The therapeutic response would be to 1. Inform the charge nurse so the physician can change to another drug. 2. Explain that this happens frequently and there is nothing to be concerned about. 3. Ask the patient when she takes the drug during the day. 4. Tell the patient to take an antacid with the drug.

9 A patient is started on ASA therapy. She tells the nurse that she is having a great deal of gastrointestinal distress. The therapeutic response would be to 1. Inform the charge nurse so the physician can change to another drug. 2. Explain that this happens frequently and there is nothing to be concerned about. 3. Ask the patient when she takes the drug during the day. 4. Tell the patient to take an antacid with the drug.

10 A 53-year-old female patient has returned to the unit following a laparoscopic cholecystectomy. She complains of right shoulder pain. The nurse would explain to the patient that this pain is 1. Common following this type of operation 2. Expected after general anesthesia. 3. Unusual and will be reported to the surgeon. 4. Indicative of a need to use the incentive spirometer.

11 A 53-year-old female patient has returned to the unit following a laparoscopic cholecystectomy. She complains of right shoulder pain. The nurse would explain to the patient that this pain is 1. Common following this type of operation 2. Expected after general anesthesia. 3. Unusual and will be reported to the surgeon. 4. Indicative of a need to use the incentive spirometer.

12 A patient with a bile duct obstruction is jaundiced. The priority intervention to control the itching associated with jaundice is to 1. Be sure the patient’s nails are clean and short. 2. Maintain the room temperature at 72’-75’ F. 3. Provide tepid water for bathing. 4. Use alcohol for back rubs.

13 A patient with a bile duct obstruction is jaundiced. The priority intervention to control the itching associated with jaundice is to 1. Be sure the patient’s nails are clean and short. 2. Maintain the room temperature at 72’-75’ F. 3. Provide tepid water for bathing. 4. Use alcohol for back rubs.

14 When a patient is in liver failure, which of the following behavioral changes is the most important assessment to report? 1. Shortness of breath 2. Lethargy. 3. Fatigue. 4. Nausea.

15 When a patient is in liver failure, which of the following behavioral changes is the most important assessment to report? 1. Shortness of breath 2. Lethargy. 3. Fatigue. 4. Nausea.

16 A 55-year-old patient with severe epigastric pain due to acute pancreatitis has been admitted to the hospital. The patient’s activity at this time should be 1. Ambulation as desired. 2. Bedrest in supine position. 3. Up ad lib and right side-lying position in bed. 4. Bedrest in Fowler’s position.

17 A 55-year-old patient with severe epigastric pain due to acute pancreatitis has been admitted to the hospital. The patient’s activity at this time should be 1. Ambulation as desired. 2. Bedrest in supine position. 3. Up ad lib and right side-lying position in bed. 4. Bedrest in Fowler’s position.

18 A patient with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include NPO, IV therapy, and bedrest. In addition to assessing for nausea, vomiting, and anorexia, the nurse should observe for pain 1. In the right lower quadrant. 2. After ingesting food. 3. Radiating to the left shoulder. 4. In the right upper quadrant.

19 A patient with a history of cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include NPO, IV therapy, and bedrest. In addition to assessing for nausea, vomiting, and anorexia, the nurse should observe for pain 1. In the right lower quadrant. 2. After ingesting food. 3. Radiating to the left shoulder. 4. In the right upper quadrant.

20 A patient scheduled for colostomy surgery will have a preoperative diet ordered that will include. 1. Broiled chicken, baked potato, and wheat bread. 2. Ground hamburger, rice and salad. 3. Broiled fish, rice, squash, and tea. 4. Steak, mashed potatoes, raw carrots, and celery.

21 A patient scheduled for colostomy surgery will have a preoperative diet ordered that will include. 1. Broiled chicken, baked potato, and wheat bread. 2. Ground hamburger, rice and salad. 3. Broiled fish, rice, squash, and tea. 4. Steak, mashed potatoes, raw carrots, and celery.

22 Lactulose is ordered for a 68-year- old patient hospitalized with hepatic failure. The nurse knows that the primary action of this drug is to 1. Prevent constipation. 2. Decrease the blood ammonia level. 3. Increase intestinal peristalsis. 4. Prevent portal hypertension.

23 Lactulose is ordered for a 68-year- old patient hospitalized with hepatic failure. The nurse knows that the primary action of this drug is to 1. Prevent constipation. 2. Decrease the blood ammonia level. 3. Increase intestinal peristalsis. 4. Prevent portal hypertension.

24 A female patient has orders for an oral cholecystogram. Prior to the test, the nursing intervention would be to 1. Provide a high-fat diet for dinner, then NPO. 2. Explain that diarrhea may result from the dye tablets. 3. Administer the dye tablets following a regular diet for dinner. 4. Administer enemas until clear.

25 A female patient has orders for an oral cholecystogram. Prior to the test, the nursing intervention would be to 1. Provide a high-fat diet for diner, then NPO. 2. Explain that diarrhea may result from the dye tablets. 3. Administer the dye tablets following a regular diet for dinner. 4. Administer enemas until clear.

26 When a patient has peptic ulcer disease, the nurse would expect a priority intervention to be 1. Assisting in inserting a Miller-Abbott tube. 2. Assisting in inserting an arterial pressure line. 3. Inserting a nasogastric tube. 4. Inserting an IV.

27 When a patient has peptic ulcer disease, the nurse would expect a priority intervention to be 1. Assisting in inserting a Miller-Abbott tube. 2. Assisting in inserting an arterial pressure line. 3. Inserting a nasogastric tube. 4. Inserting an IV.

28 The nurse is assigned to work with a patient diagnosed as having pernicious anemia. In evaluating the diet for the patient, the nurse would know the patient understands dietary parameters when he chooses. 1. Meat, milk, cheese 2. Whole grains, cereals. 3. Fruits, green leafy vegetables. 4. Organ meats, yellow vegetables.

29 The nurse is assigned to work with a patient diagnosed as having pernicious anemia. In evaluating the diet for the patient, the nurse would know the patient understands dietary parameters when he chooses. 1. Meat, milk, cheese. 2. Whole grains, cereals. 3. Fruits, green leafy vegetables. 4. Organ meats, yellow vegetables.

30 After removing the fecal impaction, the patient complains of feeling lightheaded and the pulse rate is 44. The priority intervention is to 1. Monitor vital signs. 2. Place in shock position. 3. Call the physician. 4. Begin CPR.

31 After removing the fecal impaction, the patient complains of feeling lightheaded and the pulse rate is 44. The priority intervention is to 1. Monitor vital signs. 2. Place in shock position. 3. Call the physician. 4. Begin CPR.

32 Which nursing action is the most critical when caring for a patient who is receiving continuous nasogastric tube feedings? 1. Warming the feeding to room temperature. 2. Maintain accurate records of intake and output. 3. Flushing the tube with water every 4 hours. 4. Keeping the patient in a semi-Fowler’s position.

33 Which nursing action is the most critical when caring for a patient who is receiving continuous nasogastric tube feedings? 1. Warming the feeding to room temperature. 2. Maintain accurate records of intake and output. 3. Flushing the tube with water every 4 hours. 4. Keeping the patient in a semi-Fowler’s position.

34 A patient has reported to the ambulatory surgical center for a hernia repair. While in the preoperative area, the patient tells the nurse he is very nervous about the surgery. The best response by the nurse is 1. “What did the physician tell you she is planning to do?” 2. “Do you usually get nervous about new experiences?” 3. “Your physician is very competent and will help you get better.” 4. “Tell me how you are feeling right now.”

35 A patient has reported to the ambulatory surgical center for a hernia repair. While in the preoperative area, the patient tells the nurse he is very nervous about the surgery. The best response by the nurse is 1. “What did the physician tell you she is planning to do?” 2. “Do you usually get nervous about new experiences?” 3. “Your physician is very competent and will help you get better.” 4. “Tell me how you are feeling right now.”

36 The nurse is teaching a patient with a new colostomy how to apply an appliance to a colostomy. How much skin should remain exposed between the stoma and the ring of the appliance? 1. 1/8 inch. 2. ½ inch. 3. ¾ inch. 4. I inch.

37 The nurse is teaching a patient with a new colostomy how to apply an appliance to a colostomy. How much skin should remain exposed between the stoma and the ring of the appliance? 1. 1/8 inch. 2. ½ inch. 3. ¾ inch. 4. I inch.

38 A patient is admitted with a diagnosis of esophageal varices. When collecting data, the nurse will expect to find which of the following conditions that contributed to the diagnosis. 1. Decreases prothrombin formation. 2. Decreased albumin formation by the liver. 3. Portal hypertension. 4. Increased central venous pressure.

39 A patient is admitted with a diagnosis of esophageal varices. When collecting data, the nurse will expect to find which of the following conditions that contributed to the diagnosis. 1. Decreases prothrombin formation. 2. Decreased albumin formation by the liver. 3. Portal hypertension. 4. Increased central venous pressure.

40 One of the major goals of therapy for a patient with peptic ulcer disease is to 1. Talk about the recent stressful situations, which may have contributed to the ulcer formation. 2. Understand the pathogenesis of the ulcer. 3. Accept that stress will negatively affect the condition. 4. Discover what food caused pain.

41 One of the major goals of therapy for a patient with peptic ulcer disease is to 1. Talk about the recent stressful situations, which may have contributed to the ulcer formation. 2. Understand the pathogenesis of the ulcer. 3. Accept that stress will negatively affect the condition. 4. Discover what food caused pain.

42 Evaluating the effectiveness of preoperative teaching before colostomy surgery, the nurse expects that the patient will be able to 1. Describe how the procedure will be done. 2. Exhibit acceptance of the surgery. 3. Explain the function of the colostomy. 4. Apply the colostomy bag correctly.

43 Evaluating the effectiveness of preoperative teaching before colostomy surgery, the nurse expects that the patient will be able to 1. Describe how the procedure will be done. 2. Exhibit acceptance of the surgery. 3. Explain the function of the colostomy. 4. Apply the colostomy bag correctly.

44 For a patient with the diagnosis of acute pancreatitis, the nurse would include which critical component as part of the care plan? 1. Testing for Homan’s sign. 2. Measuring the abdominal girth. 3. Performing a glucometer test. 4. Straining the urine.

45 For a patient with the diagnosis of acute pancreatitis, the nurse would include which critical component as part of the care plan? 1. Testing for Homan’s sign. 2. Measuring the abdominal girth. 3. Performing a glucometer test. 4. Straining the urine.


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