Nokea
A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a small-bore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
- A. Aspirate gastric contents
- B. Auscultate air insufflated through the tube
- C. Obtain a chest x-ray
- D. Place the tip of the tube under water and observe for air bubbles
Correct Answer: C
Rationale: A chest x-ray is the most reliable method to confirm small-bore feeding tube placement, as other methods may be inconclusive or unreliable.
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The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:
- A. Apply ice to the arm
- B. Elevate the arm
- C. Notify the physician immediately
- D. Massage the arm
Correct Answer: C
Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.
The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?
- A. Refrain from eating fresh fruits and vegetables.
- B. Avoid using another family member's toothbrush.
- C. Clean the commode after each bowel movement.
- D. Boil water prior to drinking and place open containers in the refrigerator.
- E. Inform the dentist of his diagnosis.
Correct Answer: B, E
Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (A), cleaning the commode (C), and boiling water (D) are unrelated to hepatitis B transmission.
A 24-year-old graduate student recognizes that he has a phobia傳He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
- B. He enters a concert, but as the lights dim, he does not experience anxiety.
- C. He states that he no longer fears dark places.
- D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
Correct Answer: A
Rationale: This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness.'
- B. Just don't pay attention to the voices. They'll go away after some medication.'
- C. You can't leave here. This unit is locked and the doctor has not ordered your discharge.'
- D. We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
Which medication does the nurse expect to be ordered for the postpartal patient with bleeding uncontrolled by Pitocin (oxytocin)?
- A. Methergine (methylergonovine maleate)
- B. Aquamephyton (phytonadione)
- C. Amicar (aminocaproic acid)
- D. Celestone (betamethasone)
Correct Answer: A
Rationale: Methergine is used to treat postpartum hemorrhage unresponsive to Pitocin by promoting uterine contractions. Aquamephyton is for clotting, Amicar is for fibrinolysis, and Celestone is a corticosteroid, none of which address uterine bleeding.