Nokea
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
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Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.
Which of the following prescriptions should the nurse clarify?
- A. Digoxen 250 PO daily
- B. Metoprolol 50 mg PO twice daily
- C. Furosemide 40 mg IV once daily
- D. Acetaminophen 650 mg PO every 6 hours PRN pain
Correct Answer: A
Rationale: The correct answer is A. Digoxin is commonly prescribed in mcg, not mg. Therefore, the nurse should clarify the dosage unit. Metoprolol (B) is a typical dose and frequency for oral administration. Furosemide (C) is a standard dose and route for IV administration. Acetaminophen (D) is a common dose and frequency for pain management. The other choices are not problematic.
The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
- A. Uneven shoulder and pelvic heights
- B. Symmetrical scapulae
- C. Equal leg lengths
- D. Straight spinal alignment
Correct Answer: A
Rationale: The correct answer is A. Uneven shoulder and pelvic heights are indicative of scoliosis due to the lateral curvature of the spine. Symmetrical scapulae, equal leg lengths, and straight spinal alignment are not typical signs of scoliosis. Symmetrical scapulae and equal leg lengths suggest normal alignment, while straight spinal alignment does not reflect the characteristic curvature seen in scoliosis cases. Therefore, identifying uneven shoulder and pelvic heights is crucial in recognizing scoliosis.