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A client is receiving continuous enteral nutrition through a nasogastric small-bore silicone feeding tube. What should the nurse plan for when this client has a computed tomography (CT) scan ordered?
- A. Ask the healthcare provider to re-schedule the scan
- B. Send a suction catheter with the client in case of aspiration during the scan
- C. Shut the feeding off 30-60 minutes before the scan
- D. Connect the feeding tube to continuous suction before and during the exam
Correct Answer: C
Rationale: Stopping feeding 30-60 minutes before the scan reduces aspiration risk and prevents stomach contents from interfering with imaging.
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A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)
- A. Beta-blocking agent
- B. Diuretic
- C. Opioid analgesic
- D. Lactulose
- E. Sedative
Correct Answer: A,B,D
Rationale: Beta-blockers reduce portal pressure, diuretics manage ascites, and lactulose treats hepatic encephalopathy.
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
- A. Instruct the client to lean forward.
- B. Ask the client to extend the arms.
- C. Dorsiflex the client's foot.
- D. Measure the abdominal girth.
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Determine if pain radiates to the left arm
- C. Check the client's blood pressure
- D. Auscultate heart tones
Correct Answer: A
Rationale: ECG is the primary diagnostic tool for MI, showing characteristic ST changes.
A student nurse asks the RN about the clinical manifestations of a thoracic aortic aneurysm. Which of the following findings should the nurse discuss? (Select all that apply).
- A. Shortness of breath
- B. Difficulty swallowing
- C. Upper chest pain
- D. Diaphoresis
- E. Cough
- F. Hoarseness
Correct Answer: A,B,C,E,F
Rationale: These reflect compression of adjacent structures (trachea, esophagus, recurrent laryngeal nerve) by the aneurysm.
A nurse is planning care for a client who has undergone cardiac catheterization through the femoral artery. Which of the following actions should the nurse plan to take?
- A. Instruct the client to perform range-of-motion exercises to his lower extremities.
- B. Ambulate the client 1 hour following the procedure.
- C. Restrict the client's fluid intake.
- D. Assess the color, temperature, and pulse in the affected extremity.
Correct Answer: D
Rationale: Assessing the extremity monitors for vascular complications like bleeding or occlusion post-catheterization.