Nokea
A nurse is preparing to insert a nasogastric tube (NGT) in a client. Which action should the nurse take first?
- A. Assess the client's history for nasal trauma or surgery
- B. Ask the client to cough and deep breathe.
- C. Measure the length of the tube to be inserted.
- D. Explain the procedure to the client and obtain consent.
Correct Answer: D
Rationale: The correct first action for the nurse to take when preparing to insert a nasogastric tube (NGT) in a client is to explain the procedure to the client and obtain consent. It is crucial to ensure that the client is informed about the procedure, understands it, and consents to it before proceeding. Assessing the client's history for nasal trauma or surgery (Choice A) is important but can be done after obtaining consent. Asking the client to cough and deep breathe (Choice B) is not directly related to the initial step of preparing for NGT insertion. Measuring the length of the tube to be inserted (Choice C) is a necessary step but should come after explaining the procedure and obtaining consent.
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The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?
- A. Call the healthcare provider who wrote the prescription
- B. Attempt to clarify the prescriptions with the pharmacist
- C. Administer the medications as prescribed
- D. Ask another healthcare provider for clarification
Correct Answer: A
Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
- A. Document the extent of the bruising in the medical record.
- B. Apply a cold compress to the area.
- C. Elevate the affected limb.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.
A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?
- A. Apical pulse of 58 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Presence of a new murmur
- D. Respiratory rate of 18 breaths per minute
Correct Answer: A
Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Positive urine ketones
Correct Answer: C
Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis in a client with DKA, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis, which is reflected by a low serum bicarbonate level. Correcting the low serum bicarbonate is crucial to normalize the metabolic acidosis and improve the client's condition. While elevated serum glucose (choice A) and urine ketones (choice D) are characteristic of DKA, addressing the metabolic acidosis takes precedence. Serum potassium (choice B) levels may also need monitoring and management, but correcting the acidosis is the priority to prevent complications like cardiovascular collapse.
The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?
- A. Cognitive.
- B. Affective.
- C. Comprehension.
- D. Psychomotor.
Correct Answer: B
Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife's ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.