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A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
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The nurse should identity which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D. Herpes zoster is a contraindication for certain treatments because it is a viral infection that can worsen with immunosuppressive therapy. Hypertension, obesity, and hypothyroidism are not direct contraindications for receiving the treatment mentioned. Hypertension can be managed, obesity and hypothyroidism do not directly impact the treatment's efficacy. Herpes zoster, on the other hand, can lead to serious complications if the treatment suppresses the immune system. It is crucial to address active infections before starting immunosuppressive therapy to prevent further complications.
Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer:
Rationale: Correct Answer: B. How to secure the tracheostomy tube with ties at the back of the neck.
Rationale: Securing the tracheostomy tube with ties is crucial to prevent accidental dislodgement and ensure proper placement for oxygenation. This step helps maintain the airway and prevents complications. Teaching this ensures safety and proper care for the client.
Incorrect Choices:
A: Operating the portable suction machine is important but not the priority for discharge teaching.
C: Changing the nondisposable tracheostomy tube daily is not recommended as it can increase the risk of infection.
D: Changing the tracheostomy dressing using clean technique is essential, but securing the tube takes precedence in discharge teaching.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalga
- C. Renal calculi
- D. Fibrocystic breast disease
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. Hypertension can be exacerbated by hormonal contraceptives, leading to serious complications like stroke or heart attack. It is crucial for women with hypertension to avoid estrogen-containing contraceptives.
B: Fibromyalgia, C: Renal calculi, D: Fibrocystic breast disease are not contraindications to combination oral contraceptive use. Fibromyalgia is a chronic pain disorder, renal calculi are kidney stones, and fibrocystic breast disease is a benign breast condition. These conditions do not impact the safety or efficacy of hormonal contraceptives.
For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
- A. Administer famotidine 20 mg via intermittent IV infusion twice daily.
- B. insert an indwelling urinary catheter.
- C. Administer lactated Ringer's 1L via IV bolus.
- D. Insert a nasogastric tube and maintain low intermittent suction.
Correct Answer: A,C,D
Rationale: [Explanation: The correct answer is - A,C,D. Administering famotidine helps reduce stomach acid, beneficial for clients with gastric issues. Lactated Ringer's IV bolus helps with fluid resuscitation. Inserting a nasogastric tube can help with decompression or feeding. Inserting an indwelling urinary catheter is not typically provider-initiated unless medically necessary. Therefore, A, C, and D are anticipated for client care, while B is contraindicated unless specifically indicated.]