Question 1

A nurse is caring for a patient receiving total parenteral nutrition (TPN).Which nursing action is most appropriate to implement?

Accepted Answer

Monitoring the temperature for elevation is important because TPN solutions can promote bacterial growth if not stored and administered properly. Using aseptic technique instead of clean technique is recommended for site care to prevent infection. Infusing TPN rapidly can cause hyperosmolarity, which can lead to electrolyte imbalances and other complications. Medications should not be administered through the TPN line without verifying compatibility, as some medications can interact with TPN and cause precipitates or other adverse effects.

Question 2

What information about when and where specific digestion of food takes place should be included in a patient teaching plan? (Select all that apply.)

Accepted Answer

A) Renin, found in the stomach, specifically targets and breaks down milk protein, making it an important digestive enzyme for infants who consume a milk-based diet. B) Lipase, although more commonly associated with the pancreas, also acts in the stomach to initiate the digestion of fats. C) Pepsin is a crucial enzyme in the stomach that starts the process of protein digestion, breaking down proteins into smaller peptides. D) The liver produces bile that emulsifies fats, and the pancreas secretes enzymes like pancreatic lipase into the small intestine (small bowel) to continue the digestion of fats into fatty acids and glycerol, making their absorption possible. E) is incorrect because ptyalin, or salivary amylase, begins the digestion of carbohydrates in the mouth, not the colon.

Question 3

A nurse administers promethazine (Phenergan)for nausea.Which extra precautionary action should the nurse implement because of the common side effect of antiemetic medications?

Accepted Answer

Antiemetic medications, such as promethazine, can cause drowsiness or sedation, which can increase the risk of falls. Therefore, the nurse should put up side rails to prevent falls. Checking vital signs, adding a blanket, or providing extra water are not necessarily related to the common side effect of antiemetic medications.

Question 4

A patient complains about the placement of the total parenteral nutrition (TPN)line and asks why it cannot be inserted in the arm.What fact regarding the placement of this line should the nurse base a response on?

Accepted Answer

The subclavian artery allows for rapid dilution of TPN, which is necessary due to its high osmolarity. This helps prevent irritation and damage to the vessel lining, which could occur if TPN were infused through smaller vessels with slower blood flow, such as those in the arm.

Question 5

After receiving a tube feeding, a nurse assesses the patient to be sweaty with abdominal distention and diarrhea.What is the most likely cause of this response?

Accepted Answer

The patient's symptoms of sweating, abdominal distention, and diarrhea are consistent with dumping syndrome, which can occur in some patients after a tube feeding. Dumping syndrome occurs when food or fluid rapidly moves into the small intestine, leading to an increase in fluid in the bowel and causing symptoms such as abdominal pain, diarrhea, sweating, and flushing.

Question 6

A patient inquires if this newer type of gastric analysis is going to require passage of a nasogastric tube.What is the nurse's most accurate reply?

Accepted Answer

The newer type of gastric analysis mentioned in the question is likely referring to the gastric emptying study, which involves ingesting food or a liquid containing a small amount of radioactive material and then having images taken to track how quickly the substance moves through the stomach and into the small intestine. This type of test does not involve the use of dye or the passage of a nasogastric tube. Instead, the patient ingests the substance orally and the images are taken over a period of time to track the movement. Choice A, C, and D all refer to tests that do involve the use of dye and/or a nasogastric tube, but these are not the same as the gastric emptying study.

Question 7

A nurse has collected several stool specimens for ova and parasites that are to be sent to the laboratory.What action is most appropriate for the nurse to implement?

Accepted Answer

Stool specimens for ova and parasite testing should be delivered to the laboratory as soon as possible to ensure the most accurate results. Delays can affect the viability of parasites and the integrity of the sample.

Question 8

After abdominal surgery, a patient must cough and take deep breaths.How can the nurse best achieve this with this patient?

Accepted Answer

Helping the patient splint the incision with a pillow can provide support and decrease pain during coughing and deep breathing exercises, making it more likely for the patient to complete them. Withholding analgesics or using fear tactics (such as mentioning pneumonia) can cause anxiety and decrease the patient's willingness to participate. Ambulation may increase oxygenation, but it may also be too strenuous for the patient immediately following abdominal surgery.

Question 9

What is the most current endoscopic procedure for examining the small intestine?

Accepted Answer

The most current endoscopic procedure for examining the small intestine is capsule camera or wireless capsule endoscopy. It is a non-invasive procedure where the patient swallows a small capsule with a tiny camera that captures images of the small intestine as it travels through the digestive system. This allows for visualization of areas that are difficult to reach with other endoscopic procedures. Fiberoptic light probes and rigid lighted tubes are more invasive and may cause discomfort or require sedation, while flat plate imaging is not as comprehensive as capsule camera.

Question 10

Which patient assessment indicates hyperglycemia with TPN feeding?

Accepted Answer

An increase in urine output is a common sign of hyperglycemia, as the body attempts to excrete excess glucose through the urine. This can occur with TPN (total parenteral nutrition) feeding if the glucose content is too high for the patient's current metabolic needs or insulin capacity.

Question 11

A nurse is preparing to give a tube feeding using a large syringe.What action should the nurse implement before starting the infusion?

Accepted Answer

Checking for residual formula before administering a new feeding ensures that the previous feeding has been adequately digested and helps prevent overfeeding and aspiration. Returning the residual to the stomach helps maintain electrolyte and fluid balance.

Question 12

The TPN feeding is running at 20 mL and is 1 hour behind schedule.What is the most appropriate initial nursing intervention?

Accepted Answer

The most appropriate initial nursing intervention is to document the event and inform the charge nurse. This ensures that the delay is recorded and the appropriate personnel are aware, allowing for further assessment and decision-making regarding the feeding schedule.

Question 13

Stool softeners are prescribed to promote normal elimination of feces.What is the most appropriate way to ensure effectiveness of this type of drug?

Accepted Answer

Stool softeners work by adding moisture to the stool, making it easier to pass. Adequate fluid intake is necessary to ensure the stool softener can work effectively. Without enough fluids, stool can still become hard and difficult to pass. Mouth care, ambulation, and high-fiber diet are all important aspects of overall bowel health, but they are not directly related to the effectiveness of stool softeners.

Question 14

Which set of findings best indicates that a patient with intestinal obstruction has achieved normal hydration?

Accepted Answer

The patient's pulse and blood pressure being within their normal range indicate that they have achieved normal hydration. The presence of moist mucous membranes and equal fluid intake and output further support this finding. The other options do not specifically address hydration status or provide conflicting information (e.g. low temperature in option C could indicate hypothermia and dehydration).

Question 15

A patient is being seen for the first time at a physician's office.When assisting with the assessment, a nurse notices abdominal striae.What alternative term should the nurse use when the patient asks what it is all over her abdomen?

Accepted Answer

Abdominal striae are more commonly known as stretch marks. Patients may not be familiar with the medical term and using the term "stretch marks" would be more easily understood.

Quiz 37: Digestive System Introduction

A nurse is caring for a patient receiving total parenteral nutrition (TPN) .Which nursing action is most appropriate to implement?