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A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct Answer: C
Rationale: Postoperative NG tubes decompress the stomach, preventing fluid and gas buildup that could disrupt surgical sites or cause vomiting.
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The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?
- A. Replacing the upper denture before the lower denture.
- B. Placing the unconscious client in a supine position.
- C. Brushing the tongue with a soft-bristled toothbrush.
- D. Donning clean gloves prior to performing oral hygiene.
Correct Answer: B
Rationale: B: The unconscious client should be placed in a side-lying position with the head turned to the side to prevent aspiration. A: Replacing the upper denture first is correct for ease of insertion. C: Brushing the tongue removes debris, reducing infection risk. D: Gloves adhere to standard precautions for oral care.
For a client requiring total oral care, it is important for the nurse to:
- A. assemble all equipment, assist the client to semi-Fowler's position, and place a towel on his chest.
- B. place client in Fowler's position, prepare the equipment, and tell the client what to do.
- C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- D. use gloves and clean the client's mouth, including the tongue.
Correct Answer: C
Rationale: Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn.
The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client's PEG tube was changed 6 months ago.
- D. The client's indwelling urinary catheter was last changed 5 days ago.
Correct Answer: A
Rationale: Bedridden clients should be repositioned every 2 hours to prevent skin breakdown.
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients)
- B. the profession of nursing
- C. provide high-quality care
- D. all of the above
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the nursing profession, and delivering high-quality care, ensuring comprehensive ethical practice.
The client who is Jewish is to receive a kosher meal. Which direction by the nurse to the NA is appropriate?
- A. Avoid eye contact when delivering the meal tray.
- B. Do not remove the wrapping from the plastic utensils.
- C. Have the client sit for the meal facing toward Mecca.
- D. Check that the meal contains both milk and kosher meat.
Correct Answer: B
Rationale: B: Unwrapped utensils ensure kosher compliance. A: Eye contact is not restricted. C: Facing Mecca is a Muslim practice. D: Kosher meals separate dairy and meat.