Nokea
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
- A. The nurse administers the feeding through a syringe barrel by gravity.
- B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
- C. The nurse allows the client to rest in a supine position during feeding.
- D. The nurse irrigates the NG tube with tap water after feeding.
Correct Answer: C
Rationale: Supine position during feeding increases aspiration risk; semi-Fowler's is recommended.
You may also like to solve these questions
A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).
- A. 1 tbsp honey
- B. 120 mL milk
- C. 5 hard candies
- D. 240 mL regular soda
- E. 120 mL unsweetened fruit juice
Correct Answer: A,B,C,D
Rationale: A, B, C, D provide quick sugar sources to correct hypoglycemia; unsweetened juice (E) lacks sufficient glucose.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.