Nokea
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.
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A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?
- A. Mild nausea after taking the medication.
- B. Gingival hyperplasia and rash.
- C. Slight drowsiness in the morning.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention
Clients taking anticholinergic drugs, such as benztropine mesylate (Cogentin), to relieve muscle tremors and muscle rigidity associated with Parkinson disease should be advised to avoid which of the following?
- A. Overheating
- B. Overeating
- C. Excessive fluid intake
- D. Skipping meals
Correct Answer: A
Rationale: Anticholinergics like benztropine reduce sweating, increasing the risk of overheating (A). Overeating (B), excessive fluids (C), or skipping meals (D) are not directly related to anticholinergic side effects.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- A. Intrauterine device
- B. Oral contraceptives
- C. Diaphragm
- D. Contraceptive sponge
Correct Answer: C
Rationale: The diaphragm is suitable for diabetic clients as it avoids hormonal effects that could impact glucose control.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- A. Magnesium sulfate
- B. Calcium gluconate
- C. Dinoprostone (Prostin E.)
- D. Bromocrystine (Parlodel)
Correct Answer: C
Rationale: Dinoprostone is used to induce uterine contractions and facilitate expulsion in a missed abortion.
The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
- A. The need for oxygen therapy
- B. A history of claustrophobia
- C. A permanent pacemaker
- D. Sensory deafness
Correct Answer: C
Rationale: A permanent pacemaker is a contraindication for an MRI due to the risk of device malfunction in a magnetic field.