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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 in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A. Topical ointment
- B. Sustained-release
- C. Sublingual
- D. Transdermal patch
Correct Answer: C
Rationale: Sublingual nitroglycerin has the fastest onset (1-3 minutes) due to direct absorption into bloodstream.
A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
- A. Administer antiemetics as needed.
- B. Administer analgesics as needed.
- C. NPO (nothing by mouth) until pain-free.
- D. Monitor blood glucose and provide insulin as needed.
- E. Side-lying or fetal position.
- F. Monitor hydration status.
Correct Answer: A,B,C,D,F
Rationale: These interventions address pain management, pancreatic rest, glucose control, and hydration in acute pancreatitis.
A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
- A. A headache is an indication of an allergy to the medication.
- B. A headache is an expected adverse effect of the medication.
- C. A headache is likely due to the anxiety about the chest pain.
- D. A headache indicates tolerance to the medication.
Correct Answer: B
Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilating effects on cerebral arteries.