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The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
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An adult admitted for surgery also is diagnosed with obsessive-compulsive disorder. The client spends most of her time in the bathroom washing her hands. The client is scheduled for surgery at 8:00 A.M. and is to be premedicated at 7:00 A.M. Which nursing action will be most appropriate?
- A. Inform the client at 6:30 A.M. that she will soon be medicated and have to stay in bed after that.
- B. When medicating the client, explain to her that she will not be able to get up after receiving the medication.
- C. After medicating the client, place a wash basin and wash cloth at the bedside for her use.
- D. After medicating the client, assist her in washing her hands at the bedside.
Correct Answer: C
Rationale: Providing a wash basin accommodates her OCD hand-washing ritual, reducing anxiety post-medication while ensuring she remains in bed.
The nurse is caring for a client who has a prescription for nalbuphine 10 mg/70 kg subcutaneously once. The client weighs 187 lb (85 kg). The nurse has nalbuphine 10 mg/1 mL available. How many mL should the nurse administer to the client? Record your answer using 1 decimal place.
Correct Answer: 1.2
Rationale: Dose = (10 mg/70 kg) × 85 kg = 12.14 mg. Volume = 12.14 mg ÷ 10 mg/mL = 1.2 mL.
The nurse is caring for a client with Cushing syndrome. Which of the following clinical manifestations should the nurse expect? Select all that apply.
- A. Hyperglycemia
- B. Hypertension
- C. Hyponatremia
- D. Truncal obesity
- E. Weight loss
Correct Answer: A,B,D
Rationale: Cushing syndrome causes hyperglycemia, hypertension, and truncal obesity due to excess cortisol. Hyponatremia and weight loss are not typical.
A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time?
- A. Ask about the client's recent bowel and bladder habits
- B. Assess the home for sources of excessive noise
- C. Provide information about respite and adult day care
- D. Review behavior-management techniques with caregiver
Correct Answer: B
Rationale: Assessing for environmental triggers like noise is the priority, as it may contribute to agitation in Alzheimer's. Other actions are secondary.
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
- A. a report of 10 pounds weight loss in the last month
- B. a comment by the client 'I just can't sit still.'
- C. the appearance of eyeballs that appear to 'pop' out of the client's eye sockets
- D. a report of the sudden onset of irritability in the past 2 weeks
Correct Answer: C
Rationale: Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.