Nokea
A client with pancreatic cancer is experiencing severe pain and is suspected to have a malignant bowel obstruction. The nurse should anticipate an order for:
- A. A nasogastric tube.
- B. Oral laxatives.
- C. A high-fiber diet.
- D. Immediate surgery.
Correct Answer: A
Rationale: A nasogastric tube is used to decompress the bowel and relieve symptoms in malignant bowel obstruction, providing palliative relief.
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A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?
- A. Avoid activities that elicit the Valsalva maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding the Valsalva maneuver (e.g., straining) prevents increased pressure that could dislodge packing or cause bleeding. Aspirin increases bleeding risk. Tooth brushing is safe with care. Heat may increase swelling; cold is preferred.
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
- A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.
- B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.
- C. Assist the client out of bed to sit upright in a chair for 1 hour.
- D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.
Correct Answer: C
Rationale: Sitting upright in a chair for 1 hour after a bolus tube feeding minimizes aspiration risk by promoting gastric emptying and reducing reflux.
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
- A. Bring a small glass of juice, and locate the client.
- B. Call the client's physician.
- C. Check the computerized care plan to determine the test.
- D. Send the nurse's assistant to the X-ray department to bring the client back to his room.
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.
The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse seems the client's identification and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next?
- A. Contact the pharmacist immediately to check the order and the barcode label for accuracy.
- B. Administer the medication now, knowing the medication is labeled and the client is identified.
- C. Report the problem to the information technology team to have the barcode system recalibrated.
- D. Ask another nurse to verify the medication and the client so the medication can be given now.
Correct Answer: A
Rationale: A barcode verification failure indicates a potential error, requiring immediate pharmacist consultation to confirm the order and ensure patient safety.
The nurse is observing a nursing student prepare to give an intramuscular (IM) injection in a client's deltoid. Which action by the student requires follow-up?
- A. Depresses the plunger of the syringe during the insertion of the needle
- B. Locates the injection site 3 finger widths below the acromion process
- C. Positions the client either lying or sitting position
- D. Dons clean gloves before administering the injection
Correct Answer: A
Rationale: Depressing the plunger during needle insertion can cause medication to leak into subcutaneous tissue, leading to improper administration and potential tissue damage.