Nokea
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Tilt her head backwards
- B. Swallow as tube passes
- C. Hold breath as tube passes
- D. Cough as tube passes
Correct Answer: B
Rationale: Swallowing assists with insertion of tube and closes off airway.
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 136/88 to 144/93
- B. 132/78 to 124/76
- C. 114/70 to 140/88
- D. 140/90 to 148/98
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Urine output 22 mL/hr for 2 hours
- B. Serum potassium level of 3.7
- C. Small T wave of ECG
- D. Serum glucose level of 180
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.