Question

A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

Answer 1

Correct Answers:

Confirm placement of the tube prior to each medication administration.

Rationale :

🔍Verifying tube placement is essential before administering medications to prevent aspiration and complications.

💊NG tubes can become dislodged easily, especially in patients with dysphagia, increasing the risk of misplacement.

🛑Administering medications through a misplaced tube may result in delivery into the lungs instead of the stomach, which is potentially fatal.

🧪Checking placement via aspiration pH or institutional protocol ensures the tube remains in the correct GI location and upholds patient safety.

📌Core Message

Confirming NG tube placement before administering medications ensures safe delivery and prevents aspiration complications.

Answer 2

Correct Answers:

"The laxative helps eliminate the barium."

Rationale :

🧻Barium is a contrast medium that can cause constipation if not expelled from the body after imaging.

💦A laxative helps move the barium through the GI tract efficiently, reducing the risk of bowel impaction.

⚠️Retained barium increases the risk of obstruction, especially in clients with slow motility.

📘Clear explanations support client understanding and improve compliance with post-procedure care.

📌Core Message

Laxatives promote removal of retained barium and prevent constipation or bowel obstruction.

Answer 3

Correct Answers:

Right lower quadrant

Rationale :

📍McBurney’s point is located in the right lower quadrant, specifically one-third of the distance from the anterior superior iliac spine to the umbilicus.

🩺This site is classically tender in clients with acute appendicitis and is a crucial diagnostic landmark.

🔎Palpating this point elicits pain when the appendix is inflamed, supporting the diagnosis before imaging confirmation.

🛑Palpating other quadrants would not provide relevant information for appendicitis and may delay timely diagnosis.

📌Core Message

McBurney’s point is found in the right lower quadrant, and tenderness here indicates potential appendicitis.

Answer 4

Correct Answers:

Asterixis

Rationale :

✋Asterixis is a flapping tremor often observed in clients with hepatic encephalopathy, resulting from elevated ammonia levels.

🧠This neurologic sign is caused by impaired cerebral function due to the toxic effects of liver failure.

🔬The nurse elicits this sign by asking the client to extend their arms and dorsiflex the wrists, observing for brief, non-rhythmic flapping movements.

📄Documenting asterixis helps establish the presence and progression of neurologic compromise due to liver dysfunction.

📌Core Message

Asterixis is a hallmark of hepatic encephalopathy caused by elevated ammonia and reflects neurologic dysfunction.

Answer 5

Correct Answers:

"l consume less caffeine and fewer spicy foods"
" I will try not to gain weight"

Rationale :

🍽️Clients with hiatal hernia should avoid caffeine and spicy foods, as these can worsen gastric reflux symptoms.

⚖️Weight management is crucial since obesity increases intra-abdominal pressure, exacerbating the hernia.

📚Clients are typically advised to remain upright after meals, not lie down, to prevent reflux.

💧Limiting fluids is not recommended unless medically indicated; adequate hydration supports digestive function.

📌Core Message

Clients with hiatal hernia benefit from avoiding reflux-triggering foods and managing body weight to reduce symptoms.

Answer 6

Correct Answers:

440

Rationale :

🧃The client consumed 4 oz of Pedialyte, which converts to 120 mL using the standard 1 oz = 30 mL conversion.

🍮Half of an 8 oz cup of clear Jell-O equals 4 oz, which also converts to 120 mL, as gelatin counts as fluid intake.

💉The client also received 200 mL of IV D5½NS, which is considered part of total fluid intake.

📊Summing 120 mL + 120 mL + 200 mL yields a total of 440 mL, and solid foods like graham crackers are excluded.

📌Core Message

Fluid intake includes only liquids and IV fluids, and accurate documentation requires converting ounces to mL and excluding solids.

Answer 7

Correct Answers:

Avoid foods high in fat.

Rationale :

🍔High-fat foods stimulate the gallbladder to contract, which can worsen biliary colic in clients with chronic cholecystitis.

⚠️Clients with this condition should follow a low-fat diet to prevent triggering painful gallbladder spasms.

📘Diets higher in complex carbohydrates and lean proteins are better tolerated and reduce stress on the biliary system.

🧂While reducing sodium is generally healthy, it does not directly impact biliary symptoms.

📌Core Message

Clients with chronic cholecystitis should avoid high-fat foods to prevent biliary colic and manage symptoms effectively.

Answer 8

Correct Answers:

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

Rationale :

💧Warm water irrigation is the first-line intervention to dislodge medication blockages in NG tubes.

🔁Using a gentle push-pull (in-and-out) motion can help break up the obstruction without damaging the tube.

🛑Pulling out or manipulating the tube without attempting irrigation may lead to displacement or the need for re-insertion.

📘This technique helps restore patency and maintains nutritional or medication delivery without delay.

📌Core Message

Warm water irrigation with a gentle push-pull technique is the safest way to clear a clogged NG tube.

Answer 9

Correct Answers:

Assess for a patent airway.

Rationale :

🫁Airway patency is always the first priority in post-surgical care, especially after oropharyngeal surgery.

🔍Edema, bleeding, or surgical trauma may obstruct the airway, making early assessment essential.

🗣️Other assessments like speech or secretion clearance are important but secondary to airway management.

📝Failure to prioritize airway could result in hypoxia, respiratory arrest, or death.

📌Core Message

In post-op care, airway assessment takes top priority to prevent life-threatening complications.

Answer 10

Correct Answers

Blank 1 Correct Option: Blood glucose level
Blank 2 Correct Option: Hemoglobin level

Rationale :

🩸The client’s blood glucose is 250 mg/dL, which is above normal and can worsen pancreatic inflammation and recovery.

🧪Hyperglycemia is common in acute pancreatitis due to impaired insulin release, and should be treated promptly.

🔻The client’s hemoglobin is critically low (8 g/dL), indicating anemia, which may impair oxygen delivery and healing.

📋Although amylase and WBC are elevated, addressing metabolic and oxygenation issues takes precedence.

📌Core Message

Prioritize correcting hyperglycemia in pancreatitis, then address anemia to support healing and oxygenation.

1 :
A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

2 :
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

3 :
A nurse is admitting a client with suspected appendicitis. In which abdominal quadrant should the nurse palpate to assess for pain at McBurney’s point?

4 :
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

5 :
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client's understanding of the teaching? (Select all that apply)

7 :
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

8 :
A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

9 :
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

10 :
A nurse is caring for a client who has acute pancreatitis.

Correct Answers

1 : A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

2 : A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

3 : A nurse is admitting a client with suspected appendicitis. In which abdominal quadrant should the nurse palpate to assess for pain at McBurney’s point?

4 : A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

5 : A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client's understanding of the teaching? (Select all that apply)

7 : A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

8 : A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

9 : A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

10 : A nurse is caring for a client who has acute pancreatitis.

Correct Answers

1 :
A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

2 :
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

3 :
A nurse is admitting a client with suspected appendicitis. In which abdominal quadrant should the nurse palpate to assess for pain at McBurney’s point?

4 :
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

5 :
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client's understanding of the teaching? (Select all that apply)

7 :
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

8 :
A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

9 :
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

10 :
A nurse is caring for a client who has acute pancreatitis.