A young woman with severe jaundice has an altered body image. The patient says, "Will I always be this horrible color?" What is the best response by the nurse?

"No. The color will fade gradually as liver inflammation decreases."

"Yes, but cosmetics can disguise the color."

"Yes, but your sclera will return to their previous white color."

"No. The color will change to freckles."

Answer and Explanation

The Correct Answer is A

A. "No. The color will fade gradually as liver inflammation decreases.": This response provides accurate information and reassurance, addressing the patient's concerns about her appearance while being supportive.

B. "Yes, but cosmetics can disguise the color.": This dismisses the patient’s concerns and is not empathetic or accurate, as jaundice usually resolves when liver function improves.

C. "Yes, but your sclera will return to their previous white color.": While the sclera may clear up, this does not address the entire issue of jaundice affecting skin color.

D. "No. The color will change to freckles.": This is misleading and untrue, potentially worsening the patient's anxiety.

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Correct Answer is A

Explanation

A. Flush the tube: Flushing the tube before administering a feeding ensures that the tube is patent and free of blockages, which helps prevent aspiration or feeding tube complications.

B. Roll the patient flat: Rolling the patient flat is not necessary for administering a tube feeding, as most feeding tubes are positioned with the head of the bed elevated to reduce the risk of aspiration.

C. Check for a residual formula and return the residual to his or her stomach: While checking for residuals is important for assessing gastric emptying and tolerance to the feeding, it is not the first action before starting the feeding.

D. Place the end of the tube in water and check for bubbles: This action is used to check the placement of the tube (i.e., confirming it is in the stomach or intestine), but it’s not directly related to the initial steps before administering a feeding.

A. Abdominal tenderness B. Abdominal spasms C. Nausea D. Flatulence

Correct Answer is A

Explanation

A. Abdominal tenderness: This can indicate serious complications, such as bowel obstruction or perforation, and must be reported immediately.

B. Abdominal spasms: This is a common side effect of lactulose due to increased bowel motility but is not immediately concerning unless severe.

C. Nausea: A mild, common side effect of lactulose that usually resolves with continued use.

D. Flatulence: A common, benign side effect caused by fermentation of lactulose in the colon.

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A young woman with severe jaundice has an altered body image. The patient says, "Will I always be this horrible color?" What is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to give a tube feeding using a large syringe. What action should the nurse implement before starting the infusion?

Correct Answer is A

Explanation

The nurse is assessing a patient taking lactulose to treat chronic constipation. Which adverse effect should the nurse immediately report to the healthcare provider?

Correct Answer is A

Explanation

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