Nursing Board Exam Reviewer Part 2 of 5
191. To ensure patency of central venous line ports, dilute heparin flushes are used in which of the following situations?
a) Daily when not in use
Daily instillation of dilute heparin flush when a port is not in use will maintain the port.
b) With continuous infusions
Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion.
c) Before blood drawing
Heparin flushes are used after blood drawing in order to prevent clotting of blood within the port.
d) When the line is discontinued
Heparin flush of ports is not necessary if a line is to be discontinued.
192. For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?
a) Enteric-coated tablets
Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.
b) Simple compressed tablets
Simple compressed tablets may be crushed and dissolved in water for patient receiving oral medications by feeding tube.
c) Buccal or sublingual tablets
Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings.
d) Soft gelatin capsules filled with liquid
The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.
193. Medium -length nasoenteric tubes are used for:
Placement of the tube must be verified prior to any feeding.
A gastric sump and nasoenteric tube are used for gastrointestinal decompression.
Nasoenteric tubes are used for gastrointestinal aspiration.
Gastric sump tubes are used to decompress the stomach and keep it empty.
194. Mercury is typically used in the placement of which of the following tubes?
Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location.
b) Gastric sump
A gastric sump is used to decompress and empty the stomach.
Dobbhoff tubes are used for enteric feeding.
Enteraflow tubes are used for enteric feeding
195. The most significant nursing problem related to continuous tube feedings is
a) potential for aspiration
Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.
b) interruption of GI integrity
Tube feedings preserve GI integrity by intraluminal delivery of nutrients.
c) disturbance in the sequence of intestinal and hepatic metabolism
Tube feedings preserve the normal sequence of intestinal and hepatic metabolism.
d) interruption in fat metabolism and lipoprotein synthesis
Tube feedings maintain fat metabolism and lipoprotein synthesis.
196. When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to
a) reassess the residual gastric content in 1 hour.
If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.
b) notify the physician.
One observation of a residual gastric content over 100 cc does not have to be reported to the physician. If the observation occurs two times in succession, the physician should be notified.
c) give the tube feeding.
If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time.
d) withhold the tube feeding indefinitely.
If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.
197. If tube feeding is continuous, the placement of the feeding tube should be checked
a) every shift.
Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.
b) every hour.
Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities.
c) every 24 hours.
Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.
d) when a tube feeding is continuous, it is unnecessary to check placement.
Even though the feedings are continuous, the placement must be assessed.
198. Decrease in absorption of which of the following vitamins in the geriatric patient results in pernicious anemia?
Vitamin B12 requires the intrinsic factor secreted by the gastric mucosa for absorption.
Lack of vitamin C may cause development of signs and symptoms of scurvy.
Vitamin D deficiency results in an inability to absorb calcium.
Vitamin B6 affects neuromuscular function.
199. Which of the following terms refers to tarry, black stools?
Melena indicates blood in the stool.
Hemarthrosis is bleeding into a joint.
Hematemesis is vomiting blood.
Pyrosis refers to heartburn.
200. Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance?
a) Minimal intake of 1.5 liters per day
If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.
b) Minimal urine output of 50 milliliters per hour
Minimal urine output may be less than 50 mL/hr.
c) Minimal urine output of 10 milliliters per hour
Minimal urine output must exceed 10 mL/hr.
d) Minimal intake of 2 liters per day
Minimal intake, as a rule of thumb, is less than 2 liters per day.
Source : Smeltzer and Bare/ Brunner and Suddarth CD