Nokea
A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?
- A. Confirm that bowel sounds are present.
- B. Measure the client's total body weight.
- C. Evaluate the client's ability to swallow.
- D. Observe for signs of fluid volume deficit.
Correct Answer: A
Rationale: Bowel sounds indicate GI function.
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A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I'm sorry, but your sibling's medical information is none of your business.
- B. I can give you those results as soon as I get them back from the lab.
- C. I can only give medical information to the client with an approved interpreter.
- D. The healthcare provider will share this information with you.
Correct Answer: C
Rationale: Approved interpreter ensures confidentiality.
A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?
- A. Offer comfort that healing can happen at any point in time.
- B. Offer strategies the spouse can use to provide comfort to the client.
- C. Suggest that the spouse go home for a while and get some sleep.
- D. Explain that the staff will strive to keep the client comfortable.
Correct Answer: D
Rationale: Reassurance about care addresses concerns.
A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?
- A. Uses normal saline to irrigate the wound.
- B. Cleans from less soiled to more soiled areas.
- C. Opens a sterile package towards the body.
- D. Places soiled dressing in a plastic bag.
Correct Answer: C
Rationale: Opening towards body risks contamination.
When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.