The nurse is assessing a patient with nausea and vomiting. Which additional autonomic symptoms that often accompany vomiting will the nurse observe?

Bradycardia, diarrhea, and flushing

Urinary urgency, chills, and dizziness

Pallor, sweating, and tachycardia

Fever, hyperventilation, and bradycardia

Answer and Explanation

The Correct Answer is C

A. Bradycardia, diarrhea, and flushing: Bradycardia is not typically associated with vomiting. Diarrhea is not a direct autonomic symptom of vomiting either.

B. Urinary urgency, chills, and dizziness: These symptoms are not typical of vomiting-related autonomic symptoms.

C. Pallor, sweating, and tachycardia: Pallor, sweating, and tachycardia are common autonomic responses to vomiting due to the body's stress response.

D. Fever, hyperventilation, and bradycardia: Fever and hyperventilation are not typically seen with vomiting. Bradycardia is less common in this context.

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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. 1 hour after meals B. 1 hour before meals C. With meals D. With a bedtime snack

Correct Answer is B

Explanation

A. 1 hour after meals: Sucralfate works by forming a protective barrier over ulcers. It is best absorbed when the stomach is empty, so taking it after meals reduces its effectiveness.

B. 1 hour before meals: Sucralfate should be administered 1 hour before meals to allow it to form a protective barrier in the stomach lining without interference from food.

C. With meals: Taking sucralfate with meals can interfere with its ability to coat the stomach effectively.

D. With a bedtime snack: Sucralfate should be taken on an empty stomach for optimal effectiveness, not with food.

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The nurse is assessing a patient with nausea and vomiting. Which additional autonomic symptoms that often accompany vomiting will the nurse observe?

Nursing Test Bank

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