Nokea
A client is receiving intermittent bolus feedings via a nasogastric tube. In which position should the nurse place the client once the feeding is complete?
- A. Supine
- B. Head of bed flat
- C. Left lateral position
- D. Head of bed elevated 30 to 45 degrees
Correct Answer: B
Rationale: After intermittent bolus feedings through a nasogastric tube, the correct position for the client is to keep the head of the bed flat. This position helps prevent vomiting and aspiration. Placing the client in a supine position (choice A) can increase the risk of aspiration. The left lateral position (choice C) is not typically used after nasogastric tube feedings. Elevating the head of the bed 30 to 45 degrees (choice D) is suitable for continuous tube feedings to reduce the risk of aspiration, but for intermittent bolus feedings, keeping the head of the bed flat is preferred to prevent regurgitation and aspiration.
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A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin (Dilantin). Which result indicates that the prescribed dose of phenytoin is therapeutic?
- A. 3 mcg/mL
- B. 8 mcg/mL
- C. 16 mcg/mL
- D. 28 mcg/mL
Correct Answer: C
Rationale: The correct answer is 16 mcg/mL (Choice C). The therapeutic serum phenytoin range is typically 10 to 20 mcg/mL. A level below this range may lead to continued seizure activity, indicating subtherapeutic levels. Choices A, B, and D are below the therapeutic range and would not be considered therapeutic for a client with a seizure disorder on phenytoin therapy.
The client with diabetes mellitus is being taught how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)
- A. I can continue to take an aspirin every 4 to 8 hours for my pain.
- B. My weight should be maintained at a body mass index of 30.
- C. Smoking should be stopped as soon as possible.
- D. A & B
Correct Answer: D
Rationale: The correct answer is D. Both statements A and B indicate a lack of understanding of CKD prevention. Taking aspirin every 4 to 8 hours can lead to kidney damage, and maintaining a body mass index (BMI) of 30 is considered overweight, which can increase the risk of developing CKD. Statement C, on the other hand, correctly addresses smoking cessation, which is crucial in preventing CKD. Therefore, choices A and B are incorrect as they do not align with CKD prevention strategies, making option D the correct choice.
A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)
- A. Decrease in urine output
- B. Blood clots present in the urine
- C. Prescription for metformin
- D. A & B
Correct Answer: D
Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.
The nurse is caring for a newly admitted patient who will receive digoxin to treat a cardiac dysrhythmia. The patient takes hydrochlorothiazide (HydroDIURIL) and reports regular use of over-the-counter laxatives. Before administering the first dose of digoxin, the nurse will review the patient's electrolytes with careful attention to the levels of which electrolytes?
- A. Calcium and magnesium
- B. Sodium and calcium
- C. Potassium and chloride
- D. Potassium and magnesium
Correct Answer: D
Rationale: Before administering digoxin, the nurse must review the patient's electrolyte levels, focusing on potassium and magnesium. Hypomagnesemia, similar to hypokalemia, can enhance the action of digitalis and lead to digitalis toxicity. Laxatives and diuretics, like hydrochlorothiazide, can deplete both potassium and magnesium. Therefore, monitoring these electrolytes is crucial to prevent potential adverse effects associated with digoxin therapy. Choice A (Calcium and magnesium) is incorrect because calcium levels are not specifically mentioned as crucial for digoxin therapy. Choice B (Sodium and calcium) is incorrect as sodium is not typically monitored in relation to digoxin therapy. Choice C (Potassium and chloride) is incorrect because although potassium is vital, chloride is not typically associated with digoxin therapy.
A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which of the following serum amylase values, noted by the nurse reviewing the results, would be expected in this client at this time?
- A. 48 units/L
- B. 97 units/L
- C. 150 units/L
- D. 395 units/L
Correct Answer: D
Rationale: The correct answer is D: "395 units/L." The normal serum amylase range is 25 to 151 units/L. In acute pancreatitis, the amylase level is greatly increased, typically exceeding the upper limit of the normal range. Choices A, B, and C fall within the normal range of serum amylase levels and would not be expected in a client with acute pancreatitis.