Question

The nurse is ready to begin a patient's feeding tube via a nasogastric (NG) feeding tube. What is the priority action the nurse should take before starting the feeding?

Answer 1

Correct Answers:

Verify placement of the NG tube

Rationale :

💎The priority action before administering any feeding via a nasogastric tube is to verify correct placement in the stomach or intestines.

💎Incorrect placement, such as in the lungs, can result in aspiration pneumonia, respiratory distress, or death if feeding is initiated.

💎Verification methods include aspiration of gastric contents with pH testing, x-ray confirmation (gold standard for initial placement), or observing for gastric residuals per facility policy.

💎Irrigating or checking the tape before confirming placement is unsafe, and attaching the tube to suction is not indicated unless ordered for decompression, not feeding.

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Answer 2

Correct Answers:

Oatmeal with cream, half a banana and turkey sausage

Rationale :

💎Clients on hemodialysis need a diet that is high in protein to replace protein lost during dialysis, but restricted in potassium, phosphorus, sodium, and fluids.

💎Oatmeal with cream, half a banana, and turkey sausage provides:

Protein from turkey sausage (needed for healing and muscle maintenance).

Controlled potassium (half a banana provides a small, safe portion of potassium, not excessive).

Oatmeal and cream provide energy without dangerously high phosphorus.

💎Other options explained:

Cheese sandwich, tomato soup, cranberry juice: High sodium and high phosphorus (cheese, tomato soup).

Scrambled eggs, English muffin, and orange juice: Eggs are good protein, but orange juice is high in potassium (unsafe).

Split-pea soup, whole-wheat toast, and nonfat milk: Legumes (peas) and milk are very high in phosphorus and potassium, not recommended.

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Answer 3

Correct Answers:

Elevated creatinine level

Rationale :

💎 Creatinine is a waste product of normal muscle metabolism that should be filtered by healthy kidneys.

💎 In chronic kidney disease (CKD), the glomerular filtration rate (GFR) decreases, reducing the kidneys’ ability to excrete creatinine.

💎 As a result, serum creatinine levels rise, making this the key laboratory finding indicative of CKD.

💎 Although CKD can also lead to anemia (low RBC and hemoglobin) due to decreased erythropoietin, this is a secondary effect rather than the main indicator.

💎 The most consistent and direct sign of CKD in lab results is elevated creatinine levels.

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Answer 4

Correct Answers:

Elevating the patient's arm on 2 pillows to promote lymphatic drainage

Rationale :

🟡 Delegation to an Unlicensed Assistive Personnel (UAP) is appropriate when the task is non-invasive, routine, and does not require nursing judgment or teaching.

🟡 Elevating the patient’s arm on pillows to promote lymphatic drainage is a safe, comfort-promoting activity that falls within the UAP’s scope of care.

🟡 Tasks such as reinforcing dressings, assessing for lymphedema, or providing teaching require nursing judgment, evaluation, or education, and therefore must remain the responsibility of the licensed nurse.

🟡 By delegating arm elevation, the nurse ensures comfort and supports lymphatic return while maintaining patient safety.

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Answer 5

Correct Answers:

Cardiac arrest

Rationale :

🔷 During hemodialysis, the patient’s blood circulates outside the body through the dialysis machine. If the blood is not warmed before being returned, the infusion of cold blood can cause a sudden drop in core body temperature (hypothermia).

🔷 Hypothermia triggers intense vasoconstriction and arrhythmias, which can ultimately lead to cardiac arrest.

🔷 Warming the blood to body temperature ensures hemodynamic stability and prevents life-threatening cardiovascular complications.

🔷 Therefore, warming is an essential safety measure during dialysis to protect the heart and maintain patient stability.

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Answer 6

Correct Answers:

Endometrial hypoplasia

Rationale :

💎 A dilation and curettage (D&C) involves dilating the cervix and scraping or suctioning tissue from the uterine lining (endometrium) for diagnostic or therapeutic purposes.

💎 It is primarily used to evaluate endometrial tissue for abnormalities such as hyperplasia, hypoplasia, polyps, or malignancy.

💎 While it may be performed to investigate abnormal uterine bleeding, infertility, or miscarriages, its main diagnostic value lies in identifying changes in the endometrial lining.

💎 It is not used to diagnose ovarian cancer, amenorrhea, or dysmenorrhea, which require different diagnostic approaches.

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Answer 7

Correct Answers:

Palpate for thrill and auscultate bruit over fistula

Rationale :

🟢 An arteriovenous (AV) fistula is created surgically to provide vascular access for hemodialysis, usually in the arm.

🟢 To check for patency, the nurse should palpate for a thrill (a vibration felt over the fistula site) and auscultate for a bruit (a swishing sound heard with a stethoscope).

🟢 The presence of both a thrill and bruit confirms that blood is flowing adequately through the fistula, which is essential for effective dialysis.

🟢 Assessing the radial or brachial artery directly does not confirm fistula function; the check must be done directly over the fistula site.

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Answer 8

Correct Answers:

Headache, deteriorating level of consciousness and twitching

Rationale :

🔶 Dialysis disequilibrium syndrome (DDS) occurs when rapid removal of urea during hemodialysis causes osmotic shifts that lead to cerebral edema.

🔶 This complication is most likely to happen during the first few dialysis treatments or when blood urea nitrogen (BUN) levels are very high.

🔶 Clinical manifestations include headache, nausea, restlessness, confusion, decreased level of consciousness, twitching, and seizures as the brain swells from fluid shifts.

🔶 Prompt recognition is critical, as severe DDS can progress to coma and death if not treated quickly by slowing or stopping dialysis.

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Answer 9

Correct Answers:

A bacterial infection

Rationale :

⭐ The primary cause of peptic ulcers is infection with Helicobacter pylori (H. pylori), a bacterium that damages the protective mucosal lining of the stomach and duodenum.

⭐ The weakened mucosa becomes more susceptible to injury from gastric acid and pepsin, resulting in ulcer formation.

⭐ While factors like stress, caffeine, and spicy foods may aggravate symptoms or delay healing, they are not the root cause.

⭐ Treatment of peptic ulcers includes antibiotic therapy to eradicate H. pylori, along with acid-reducing medications and lifestyle modifications.

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Answer 10

Correct Answers:

Meats

Rationale :

⚫ In hepatic encephalopathy, the failing liver cannot adequately metabolize ammonia, which is produced during the breakdown of dietary proteins (commonly from meats).

⚫ High protein intake worsens ammonia accumulation, leading to confusion, altered mental status, and other neurologic signs of encephalopathy.

⚫ For this reason, protein-rich foods such as meats may be temporarily restricted during acute episodes, while ensuring nutritional needs are still met with other food sources.

⚫ Once the encephalopathy improves, moderate protein is usually reintroduced to prevent malnutrition, often using vegetable proteins or supplements that are easier to process.

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Custom Med Surg II Exam 11A

No.

1 :
The nurse is ready to begin a patient's feeding tube via a nasogastric (NG) feeding tube. What is the priority action the nurse should take before starting the feeding?

2 :
The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choices by the patient indicate that the teaching has been successful?

3 :
The LPN is reviewing a patient's medical record and notes that the physician has documented that the patient has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect which finding indicative of this disorder?

4 :
The nurse is working with an UAP in caring for a Pt. who had a right breast lumpectomy and axillary node dissection. Which action can be delegated to the UAP

5 :
The nurse who assists with performing hemodialysis understands that the blood in the machine must be warmed or the patient can experience shock related to which complication?

6 :
A dilation and curettage is a diagnostic procedure used to evaluate which of the following?

7 :
The nurse is caring for a patient with a new right arm arteriovenous (AV) fistula. What action does the nurse perform to check for patency of the AV fistula?

8 :
A patient with chronic kidney disease is scheduled for hemodialysis today. The nurse at the dialysis unit knows that hemodialysis patients are at risk for Disequilibrium syndrome. Knowing this it is important to monitor each patient for which manifestations?

9 :
The nurse provides teaching for a patient with a peptic ulcer. Which of the following would the nurse include in the teaching plan as a primary cause of peptic ulcers?

10 :
A patient has advanced cirrhosis of the liver with an acute exacerbation encephalopathy. What type of food may be limited for a short time in his diet?

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Custom Med Surg II Exam 11A

No.

1 : The nurse is ready to begin a patient's feeding tube via a nasogastric (NG) feeding tube. What is the priority action the nurse should take before starting the feeding?

2 : The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choices by the patient indicate that the teaching has been successful?

3 : The LPN is reviewing a patient's medical record and notes that the physician has documented that the patient has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect which finding indicative of this disorder?

4 : The nurse is working with an UAP in caring for a Pt. who had a right breast lumpectomy and axillary node dissection. Which action can be delegated to the UAP

5 : The nurse who assists with performing hemodialysis understands that the blood in the machine must be warmed or the patient can experience shock related to which complication?

6 : A dilation and curettage is a diagnostic procedure used to evaluate which of the following?

7 : The nurse is caring for a patient with a new right arm arteriovenous (AV) fistula. What action does the nurse perform to check for patency of the AV fistula?

8 : A patient with chronic kidney disease is scheduled for hemodialysis today. The nurse at the dialysis unit knows that hemodialysis patients are at risk for Disequilibrium syndrome. Knowing this it is important to monitor each patient for which manifestations?

9 : The nurse provides teaching for a patient with a peptic ulcer. Which of the following would the nurse include in the teaching plan as a primary cause of peptic ulcers?

10 : A patient has advanced cirrhosis of the liver with an acute exacerbation encephalopathy. What type of food may be limited for a short time in his diet?

1 :
The nurse is ready to begin a patient's feeding tube via a nasogastric (NG) feeding tube. What is the priority action the nurse should take before starting the feeding?

2 :
The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choices by the patient indicate that the teaching has been successful?

3 :
The LPN is reviewing a patient's medical record and notes that the physician has documented that the patient has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect which finding indicative of this disorder?

4 :
The nurse is working with an UAP in caring for a Pt. who had a right breast lumpectomy and axillary node dissection. Which action can be delegated to the UAP

5 :
The nurse who assists with performing hemodialysis understands that the blood in the machine must be warmed or the patient can experience shock related to which complication?

6 :
A dilation and curettage is a diagnostic procedure used to evaluate which of the following?

7 :
The nurse is caring for a patient with a new right arm arteriovenous (AV) fistula. What action does the nurse perform to check for patency of the AV fistula?

8 :
A patient with chronic kidney disease is scheduled for hemodialysis today. The nurse at the dialysis unit knows that hemodialysis patients are at risk for Disequilibrium syndrome. Knowing this it is important to monitor each patient for which manifestations?

9 :
The nurse provides teaching for a patient with a peptic ulcer. Which of the following would the nurse include in the teaching plan as a primary cause of peptic ulcers?

10 :
A patient has advanced cirrhosis of the liver with an acute exacerbation encephalopathy. What type of food may be limited for a short time in his diet?