MEDSURGE FINAL EXAM 2022-LATEST UPDATE
How should the nurse determine the correct length of a nasogastric tube for placement into the stomach?
A) Place the distal tip to the nose, then the ear tip and the end of the xyphoid process.
B) Instruct the patient to lie prone and measure tip of ...
medsurge final exam 2022 latest update how should the nurse determine the correct length of a nasogastric tube for placement into the stomach a place the d
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MEDSURGE FINAL EXAM 2022-LATEST UPDATE
How should the nurse determine the correct length of a nasogastric tube for
placement into the stomach?
A) Place the distal tip to the nose, then the ear tip and the end of the xyphoid
process.
B) Instruct the patient to lie prone and measure tip of nose to umbilical area.
C) Insert the tube into nose until the tube fills with secretions.
D) Obtain an order from the physician for the number of inches to insert the
tube.
Ans A To insert the nasal gastric tube, the patient should be in a neutral
position. The tube is measured by placing the distal tip to the nose, to the
ear tip, and the end of the xyphoid process, adding 6 inches.
Which of the following should be included in the nursing management of a
nasogastric tube?
A) Confirm the placement of the nasogastric tube prior to medication
administration.
B) Have the patient sip cool water to stimulate saliva production.
C) Keep the patient in a low-Fowler's position.
D) Connect the tube to continuous wall suction.
Ans A Nursing management of the nasogastric tube includes checking
placement of the tube when using it for administration of medication. If the
NG tube is used for decompression, it is attached to intermittent low suction.
Patients with a nasogastric tube should be maintained on an NPO status.
During the placement of a nasogastric tube, the patient should be positioned
in a Fowler's position.
A patient who is having difficulty clearing the airway, has a respiratory rate
of 28 and a temperature of 38.9° C. The patient has a nasogastric tube.
What might this assessment indicate?
A) Angina
B) Hyperglycemia
C) Fistula
D) Aspiration pneumonia
Ans D Pulmonary complications from nasogastric tube placement can
occur from aspiration or impairment of clearing the airway. Signs and
symptoms include difficulty clearing the airway, tachypnea, and fever.
,The nurse is reviewing discharge instructions with a patient ordered to take
ursodeoxycholic acid (UDCA). The nurse recognizes that additional teaching
is needed regarding this medication when the patient states:
A) "It is important that I see my physician for scheduled follow-up
appointments while taking this medication."
B) "I will take this medication for 2 weeks and then gradually stop taking it."
C) "If I loose weight, the dose of the medication may change."
D) "This medication will help dissolve small gallstones made of cholesterol."
Ans B Ursodeoxycholic acid (UDCA) has been used to dissolve small,
radiolucent gallstones composed primarily of cholesterol. This drug can
reduce the size of existing stones, dissolve small stones, and prevent new
stones from forming. Six to 12 months of therapy is required in many patient
to dissolve stones, and monitoring of the patient is required during this time.
The effective dose of medication depends on body weight.
The nurse is caring for a patient who had surgery for gallbladder disease.
Which of the following finding should the nurse immediately report to the
physician?
A) Decreased breath sounds
B) Drainage of bile-colored fluid onto the abdominal
dressing C) Rigidity of the abdomen
D) Acute pain with movement
Ans C The location of the subcostal incision will likely cause the patient to
take shallow breaths to prevent pain and this may result in decreased breath
sounds. The nurse should remind patients to take deep breaths and cough to
expand the lungs fully and prevent atelectasis. Acute pain is an expected
assessment finding following surgery, and analgesics should be administered
for pain relief. Abdominal splinting or application of an abdominal binder
may assist in reducing the pain. Bile may continue to drain from the
drainage tract after surgery, and this will require frequent changes of the
abdominal dressing. Increased abdominal tenderness and rigidity should be
reported immediately to the physician, as it may indicate bleeding from an
inadvertent puncture or nicking of a major blood vessel during the surgical
procedure.
While assessing an elderly patient with gallstones, the nurse in aware that
the patient may not exhibit typical symptoms. The elderly patient may
exhibit symptoms including:
A) Fever and pain
B) Chills and jaundice
C) Nausea and vomiting
D) Septic shock and oliguria
,Ans D The elderly patient may not exhibit the typical symptoms of fever,
pain, chills jaundice, and nausea and vomiting. Symptoms of biliary tract
disease in the elderly may be accompanied or preceded by those of septic
shock, which include oliguria, hypotension, change in mental status,
tachycardia, and tachypnea.
Which stoma would you expect a malodorous, enzyme-rich, caustic liquid
output that is yellow, green, or brown?
a. Ileostomy.
b. Ascending colostomy.
c. Transverse colostomy.
d. Descending colostomy.
Ans A
Based upon the pathophysiology of acute pancreatitis, select the
priority nursing diagnosis:
A) Hyperthermia
B) Acute pain
C) Diarrhea
D) Nausea
The patient with pancreatitis is at risk for numerous complications related to
the disorder. The nurse is aware that is it necessary to assess for the onset
of complications and take measures to decrease the risk. Considering this
information, the nurse positions the patient in a:
A) Supine position
B) Lithotomy position
C) Trendelenburg
position D) Semi-
Fowler's position
Ans D
, The priority nursing diagnosis related to the care of a patient with chronic
pancreatitis with drainage through the skin and abdominal wall is:
A) Disturbed body
image B) Impaired
skin integrity
C) Nausea
D) Risk for deficient fluid volume
Ans B
What technique will the nurse use to palpate a patient's liver?
A) Place the hand under the left lower rib cage and press down lightly
with the other hand
B) Place the left hand over the abdomen and behind the left side at the 11th
rib
C) Place hand under the right lower rib cage and press down lightly with the
other hand
D) Hold the hand 90 degrees to the abdomen and push
down firmly Ans C
The nurse is aware that a patient with liver failure often requires vitamin
therapy. Which vitamin does the liver require for the synthesis of
prothrombin?
A) Vitamin B12
B) Vitamin A
C) Vitamin
D D)
Vitamin K
Ans D The liver requires vitamin K for the synthesis of prothrombin and some
of the other clotting factors. Breakdown of fatty acids into ketone bodies
occurs primarily when the availability of metabolism is limited, as during
starvation or in uncontrolled diabetes. Vitamins stored in the liver include A,
B12, D, and several of the B-complex vitamins.
A nurse practitioner teaching a class on hepatitis informs the participants
that which of the following occupations provides the greatest risk for
contracting hepatitis B?
A) Flight attendants
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