A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?
- A. Monitor intake and output every 8 hours.
- B. Flush the feeding tube every 4 hours.
- C. Measure the client's temperature every 24 hours.
- D. Change the feeding bag and tubing every 72 hours.
Correct Answer: B
Rationale: Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. Monitoring intake and output, measuring temperature, and changing the feeding bag and tubing are also important aspects of care but not directly related to maintaining the patency of the feeding tube in a client receiving continuous enteral feedings.
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The nurse double-checked Mr. Gary's meds to avoid errors. This is an example of?
- A. Risk management
- B. Quality assurance
- C. Health literacy
- D. Patient advocacy
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional is preparing to administer a subcutaneous injection. Which of the following actions should the healthcare professional take?
- A. Use a 1-inch needle.
- B. Insert the needle at a 90-degree angle.
- C. Use a tuberculin syringe.
- D. Aspirate before injecting.
Correct Answer: B
Rationale: When administering a subcutaneous injection, it is important to insert the needle at a 90-degree angle to ensure proper medication delivery into the subcutaneous tissue. This angle helps prevent the medication from being injected too deeply or too superficially, ensuring optimal absorption and therapeutic effect.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a client with a fractured mandible, often wired shut for immobilization, to cut wires in emergencies like vomiting or airway obstruction, ensuring safety post-discharge. An oral airway, pliers, or tracheostomy set isn't standard for this condition wires are the focus. Nurses emphasize this precaution, teaching clients and families its use, preventing complications from restricted jaw movement during healing.
The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?
- A. To promote health
- B. To prevent illness
- C. To restore health
- D. To facilitate coping with death and/or disability
Correct Answer: C
Rationale: Nursing practice is guided by four broad goals that shape interventions based on client needs. In this scenario, the nurse's coordination with a physical therapist to address the client's weakened right side post-stroke aligns with the goal of restoring health. This involves efforts to regain lost function, improve strength, and enhance the client's physical capacity following an illness or injury. Promoting health focuses on maintaining wellness before illness occurs, such as through lifestyle education, while preventing illness aims to stop disease onset, like via vaccinations. Facilitating coping with death or disability pertains to supporting clients and families through terminal conditions or permanent impairments, not necessarily recovery. Here, the emphasis is on rehabilitation and recovery, targeting the restoration of the client's pre-stroke abilities as much as possible. This collaborative approach underscores nursing's role in helping clients reclaim their health after a significant medical event, aligning with the restorative aim.
A healthcare professional is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the healthcare professional include?
- A. Avoid drinking grapefruit juice.
- B. Take aspirin for pain relief.
- C. Consume a consistent amount of green leafy vegetables.
- D. Use an electric razor when shaving.
Correct Answer: C
Rationale: Consuming a consistent amount of green leafy vegetables is important for clients taking warfarin as these foods contain vitamin K, which can affect the medication's effectiveness. Maintaining a consistent intake helps stabilize the International Normalized Ratio (INR) levels, which is crucial for monitoring the blood's ability to clot properly while on warfarin therapy.