A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

Sore throat

Abdominal bloating

Gag reflex

Belching

Answer and Explanation

The Correct Answer is C

Choice A rationale
While a sore throat can be a side effect of an upper endoscopy, it is not the priority for monitoring after the procedure.
Choice B rationale
Abdominal bloating can occur after an upper endoscopy, but it is not the priority for monitoring.
Choice C rationale
Monitoring the return of the gag reflex is a priority after an upper endoscopy. The gag reflex may be impaired due to the use of local anesthetics during the procedure. An impaired gag reflex increases the risk of aspiration.
Choice D rationale
Belching can occur after an upper endoscopy, but it is not the priority for monitoring

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Correct Answer is B

Explanation

Choice A rationale
Ecchymosis of the extremities is not a typical finding in a patient with an obstruction and inflammation of the common bile duct due to cholelithiasis.
Choice B rationale
Fatty stools, or steatorrhea, is a common symptom in patients with cholelithiasis. This is because the obstruction in the common bile duct can prevent the flow of bile, which is necessary for the digestion and absorption of fats.
Choice C rationale

Straw-colored urine is not typically associated with cholelithiasis. Dark urine can be a symptom of this condition, as the obstruction can cause bilirubin to leak into the blood and urine.
Choice D rationale
Tenderness in the left upper abdomen is not a typical symptom of cholelithiasis. Pain associated with this condition is usually located in the right upper quadrant or the middle upper part of the abdomen.

A. Place enough formula in the feeding bag to last for 8 hr of continuous feeding. B. Flush the tube with 30 mL of water every 4 hr. C. Change the feeding bag and tubing every 72 hr. D. Keep the head of the bed elevated at 15 degrees.

Correct Answer is B

Explanation

Choice A rationale

While it’s important to ensure the feeding bag contains enough formula for the feeding period, it’s not recommended to fill the bag with more than 4-6 hours’ worth of formula at a time due to the risk of bacterial growth.
Choice B rationale
This is the correct answer. Flushing the gastrostomy tube with water every 4 hours helps maintain tube patency and hydrates the patient.
Choice C rationale
Changing the feeding bag and tubing every 72 hours is a common practice, but it’s not the most critical intervention in this scenario.
Choice D rationale
Keeping the head of the bed elevated at 30 to 45 degrees during feeding and for 1 to 2 hours afterward is recommended to minimize the risk of aspiration. However, 15 degrees may not be sufficient.

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A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a patient who has an obstruction and inflammation of the common bile duct due to cholelithiasis. Which finding is expected for this condition?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A patient has undergone subtotal gastrectomy and is being prepared for discharge. Which reasons should the nurse consider for the care?

The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?

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