Silvestri, 3/e, ISBN 1-1460-0052-6
Unit XV (edited file)—"Comprehensive Test”
10/14/08, Page 1 of 46, 0 Figure(s), 0 Table(s), 0 Box(es)
UNIT XX
Comprehensive Test
FYI: Q52 has a Figure.
QUESTIONS
1.
Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks
for gastric residual.
The nurse understands that the rationale for checking gastric residual before
administering the tube feeding is to:
1.
Confirm proper nasogastric tube placement.
2.
Observe the digestion of formula.
3.
Check fluid and electrolyte status.
4.
Evaluate absorption of the last feeding.
Answer:
4
Rationale:
All the stomach contents are aspirated and measured before administering a tube
feeding.
This procedure measures the gastric residual.
The gastric residual is checked to
confirm whether undigested formula from a previous feeding remains, and thereby evaluates the
absorption of the last feeding.
It is important to check the gastric residual before administration
of a tube feeding.
A full stomach could result in overdistention, thus predisposing the client to
regurgitation and possible aspiration.
Test-Taking Strategy:
Note that the issue of the question is the purpose of checking residual.
Focusing on this issue should direct you to option 4.
Review this procedure if you had difficulty
with this question.
Level of Cognitive Ability:
Comprehension
Client Needs:
Physiological Integrity
Integrated Process:
Nursing Process/Data Collection
Content Area:
Adult Health/Gastrointestinal
Reference:
deWit, S. (2005).
Fundamental concepts and skills for nursing.
Philadelphia: W.B.
Saunders, p. 481.
2.
A client is complaining of gas pains following surgery and requests medication.
The nurse
selects which medication from the PRN medication list to give to the client?
1.
Magnesium hydroxide (milk of magnesia, MOM)
2.
Droperidol (Inapsine)
3.
Acetaminophen (Tylenol)
4.
Simethicone (Mylicon)
Answer:
4
Rationale:
Simethicone is an antiflatulent used in the relief of pain cause by excessive gas in the
gastrointestinal tract.
Magnesium hydroxide is an antacid and laxative.
Droperidol is used to
treat postoperative nausea and vomiting.
Acetaminophen is a non-narcotic analgesic.
Test-Taking Strategy:
Use the process of elimination and note the key words,
gas pains
.
Recalling the classifications of the medications in the options will direct you to option 4.
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Silvestri, 3/e, ISBN 1-1460-0052-6
Unit XV (edited file)—"Comprehensive Test”
10/14/08, Page 2 of 46, 0 Figure(s), 0 Table(s), 0 Box(es)
question was difficult, review this medication.
Level of Cognitive Ability:
Application
Client Needs:
Physiological Integrity
Integrated Process:
Nursing Process/Implementation
Content Area:
Pharmacology
Reference:
Hodgson, B., & Kizior, R. (2005).
Saunders nursing drug handbook 2005
.
Philadelphia: W.B. Saunders, p. 970.
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- Spring '11
- brinley
- Nursing, Florence Nightingale, content area, Calcium metabolism, Test-Taking Strategy
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