ARIZONA COLLEGE OF NURSING NURS 355 EXAM 3 STUDY
GUIDE WITH COMPLETE SOLUTION!!
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving
continuous enteral nutrition through a soft nasogastric tube. The nurse notes the
presence of new crackles in the patient's lungs. In which order will the nurse take
action? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy.
Answers :Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have occurred. The
nurse's first action should be to turn off the enteral feeding to avoid further
aspiration. The next action should be to check the oxygen saturation because this
may indicate the need for immediate respiratory suctioning or oxygen
administration. The residual volume provides data about possible causes of
aspiration. Finally, the health care provider should be notified and informed of all
the assessment data the nurse has just obtained.
Which information about an 80-yr-old male patient at the senior center is of most
concern to the nurse?
a. Decreased appetite
,b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food
Answers :Answer: Unintended weight loss
Rationale: Unintentional weight loss is not a normal finding and may indicate a
problem such as cancer or depression. Poor appetite, difficulty in chewing, and
indigestion are common in older patients. These will need to be addressed but are
not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel evacuation,
when should the nurse suggest that the patient attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal
Answers :Answer: After eating breakfast
Rationale: The gastrocolic reflex is most active after the first daily meal.
Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate
these reflexes.
What condition should the nurse anticipate when caring for a patient with a history
of a total gastrectomy?
a. Constipation
b. Dehydration
,c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency
Answers :Answer: Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor,
which is needed for cobalamin (vitamin B12) absorption. Because the stomach
absorbs only small amounts of water and nutrients, the patient is not at higher risk
for dehydration, elevated cholesterol, or constipation.
The nurse is caring for a patient with an obstructed common bile duct. What
condition should the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
d. Increased serum indirect bilirubin level
Answers :Answer: Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of fat in the
small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by
common bile duct obstruction. Serum cholesterol levels are increased with biliary
obstruction. Direct bilirubin level is increased with biliary obstruction.
The nurse receives the following information about a patient who is scheduled for
a colonoscopy. Which information should be communicated to the health care
provider before sending the patient for the procedure?
a. The patient declined to drink the prescribed laxative solution.
, b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
Answers :Answer: The patient declined to drink the prescribed laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be
visualized and the procedure would be rescheduled. Because contrast solution is
not used during colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic
resonance imaging but not to colonoscopy. The nurse should instruct the patient
about the sedation used during the examination to decrease the patient's anxiety
about discomfort.
Which statement to the nurse from a patient with jaundice indicates a need for
teaching?
a. "I used cough syrup several times a day last week."
b. "I take a baby aspirin every day to prevent strokes."
c. "I take an antacid for indigestion several times a week"
d. "I use acetaminophen (Tylenol) every 4 hours for pain."
Answers :Answer: "I use acetaminophen (Tylenol) every 4 hours for pain."
GUIDE WITH COMPLETE SOLUTION!!
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving
continuous enteral nutrition through a soft nasogastric tube. The nurse notes the
presence of new crackles in the patient's lungs. In which order will the nurse take
action? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy.
Answers :Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have occurred. The
nurse's first action should be to turn off the enteral feeding to avoid further
aspiration. The next action should be to check the oxygen saturation because this
may indicate the need for immediate respiratory suctioning or oxygen
administration. The residual volume provides data about possible causes of
aspiration. Finally, the health care provider should be notified and informed of all
the assessment data the nurse has just obtained.
Which information about an 80-yr-old male patient at the senior center is of most
concern to the nurse?
a. Decreased appetite
,b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food
Answers :Answer: Unintended weight loss
Rationale: Unintentional weight loss is not a normal finding and may indicate a
problem such as cancer or depression. Poor appetite, difficulty in chewing, and
indigestion are common in older patients. These will need to be addressed but are
not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel evacuation,
when should the nurse suggest that the patient attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal
Answers :Answer: After eating breakfast
Rationale: The gastrocolic reflex is most active after the first daily meal.
Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate
these reflexes.
What condition should the nurse anticipate when caring for a patient with a history
of a total gastrectomy?
a. Constipation
b. Dehydration
,c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency
Answers :Answer: Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor,
which is needed for cobalamin (vitamin B12) absorption. Because the stomach
absorbs only small amounts of water and nutrients, the patient is not at higher risk
for dehydration, elevated cholesterol, or constipation.
The nurse is caring for a patient with an obstructed common bile duct. What
condition should the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
d. Increased serum indirect bilirubin level
Answers :Answer: Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of fat in the
small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by
common bile duct obstruction. Serum cholesterol levels are increased with biliary
obstruction. Direct bilirubin level is increased with biliary obstruction.
The nurse receives the following information about a patient who is scheduled for
a colonoscopy. Which information should be communicated to the health care
provider before sending the patient for the procedure?
a. The patient declined to drink the prescribed laxative solution.
, b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
Answers :Answer: The patient declined to drink the prescribed laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be
visualized and the procedure would be rescheduled. Because contrast solution is
not used during colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic
resonance imaging but not to colonoscopy. The nurse should instruct the patient
about the sedation used during the examination to decrease the patient's anxiety
about discomfort.
Which statement to the nurse from a patient with jaundice indicates a need for
teaching?
a. "I used cough syrup several times a day last week."
b. "I take a baby aspirin every day to prevent strokes."
c. "I take an antacid for indigestion several times a week"
d. "I use acetaminophen (Tylenol) every 4 hours for pain."
Answers :Answer: "I use acetaminophen (Tylenol) every 4 hours for pain."
