Nokea
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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Imelda is in the recovery stage after the incident. As a nurse, you know that the diet that will be prescribed to Miss Imelda is
- A. Low calorie, High protein with Vitamin A and C rich foods
- B. High protein, High calorie with Vitamin A and C rich foods
- C. High calorie, Low protein with Vitamin A and C rich foods
- D. Low calorie, Low protein with Vitamin A and C rich foods
Correct Answer: B
Rationale: During recovery from massive tissue loss, Imelda needs a high protein, high calorie diet with vitamins A and C (B). Protein supports tissue repair and collagen synthesis, vital for wound healing. High calories provide energy for metabolic demands of recovery. Vitamins A and C enhance epithelialization and collagen formation. Low calorie options (A, D) lack energy for healing, while low protein (C, D) hinders tissue regeneration. This nutrient-rich diet matches the needs of second intention healing, where extensive repair occurs, making B the correct choice.
The nurse is caring for a client with Addison's disease. Which finding is expected with this diagnosis?
- A. Hypotension
- B. Weight gain
- C. Hyperglycemia
- D. Hypokalemia
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?
- A. Obturator
- B. Oral airway
- C. Epinephrine
- D. Tracheostomy tube with the next larger size
Correct Answer: A
Rationale: Post-tracheostomy, the obturator (A) is essential at the bedside to reinsert the tube if dislodged, ensuring airway patency. An oral airway (B) is irrelevant for tracheostomy patients. Epinephrine (C) treats allergic reactions, not routine needs. A larger tracheostomy tube (D) isn't standard emergency equipment. A is correct. Rationale: The obturator facilitates immediate tube replacement, critical in the first 72 hours before a tract forms, preventing airway loss, a priority per surgical nursing standards over other less relevant items.
Which domains of learning is responsible for making John and Marsha understand the different kinds of family planning methods?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Motivative
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Mr. Gary smokes 2 packs of cigarette a day. This is an example of?
- A. Risk factor
- B. Illness
- C. Disability
- D. Health
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.