Nokea
A client is receiving enteral feedings through a nasogastric tube, and the nurse is administering the client's medications. Which of the following can be administered through the NG tube? Select all that apply.
- A. Hard extended-release capsules (opened, crushed, and dissolved)
- B. Pills (crushed and dissolved)
- C. Enteric-coated tablets (crushed and dissolved)
- D. Liquid suspension
- E. Soft-gel capsules (dissolved)
- F. Sublingual wafer (dissolved)
Correct Answer: B,D
Rationale: Pills (crushed, dissolved) (B) and liquid suspension (D) are safe for NG administration. Extended-release (A) and enteric-coated (C) medications should not be crushed; soft-gel (E) and sublingual (F) are not suitable.
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The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- A. BP 146/88
- B. Respirations 28 shallow
- C. Weight gain of 10 pounds in 6 months
- D. Pink complexion
Correct Answer: B
Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients
The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?
- A. hemoglobin 4.8 g/dL
- B. troponin T 0.04 ng/mL
- C. phosphorus 3.8 mg/dL
- D. bilirubin (total) 0.7 mg/dL
Correct Answer: A
Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.
A child suspected of having cystic fibrosis is scheduled for a quantitative sweat test. The nurse knows that the quantitative sweat test will be analyzed using:
- A. Pilocarpine iontophoresis
- B. Choloride iontophoresis
- C. Sodium iontophoresis
- D. Potassium iontophoresis
Correct Answer: A
Rationale: Pilocarpine iontophoresis is used to stimulate sweat production for chloride analysis in cystic fibrosis diagnosis.
To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
- A. Keep the room darkened by pulling the curtains
- B. Keep the light over the bed on at all times
- C. Keep the room quiet and dim the lights
- D. Keep the television or radio turned on
Correct Answer: C
Rationale: A quiet, dimly lit room reduces sensory stimulation, decreasing the risk of seizures and hallucinations during alcohol withdrawal.