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A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?
- A. Record the coughing incident. No further action is required at this time.
- B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
- C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
- D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct Answer: C
Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.
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A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?
- A. Collaborating with providers to perform obesity screenings during routine office visits.
- B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity.
- C. Providing specialized intraoperative training in surgical treatments for obesity.
- D. Educating acute care nurses about postoperative complications related to obesity.
Correct Answer: A
Rationale: The correct answer is A: Collaborating with providers to perform obesity screenings during routine office visits. This is a primary health care strategy as it focuses on prevention and early detection, which are key components of managing obesity. Screening during routine visits allows for timely identification of obesity and related health risks, enabling early intervention. Choices B, C, and D do not align with primary health care strategies for obesity. Ensuring availability of specialized beds, providing intraoperative training, and educating about postoperative complications are more focused on secondary and tertiary levels of care, rather than primary prevention and early detection.
A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
- A. Allow extra time for the client to respond to questions
- B. Expect the client to have difficulty understanding the information
- C. Avoid references to the client's past experiences
- D. Keep the learning session private and one-on-one
Correct Answer: A
Rationale: Corrected Choice A, allowing extra time for the client to respond to questions, is the appropriate strategy when educating an older adult with type 2 diabetes mellitus. Older adults may need additional time to process information and formulate responses. Choice B is incorrect as it assumes the client will have difficulty understanding the information, which may not be the case. Choice C is incorrect because referencing the client's past experiences can help personalize the education session. Choice D is also incorrect as keeping the learning session private and one-on-one may not be necessary for all clients and may limit the potential benefits of group education and support.
A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?
- A. Place the shallow end of the fracture pan under the client's buttocks.
- B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
- C. Keep the bed flat while the client is on the fracture pan.
- D. Hyperextend the client's back while the fracture pan is in place.
Correct Answer: A
Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.
A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
- A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
- B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
- C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
- D. "We need to document the exact medication you were taking because you might be allergic to it."
Correct Answer: D
Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.
A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?
- A. Examine personal values about the issue.
- B. Respect the parents' decision and provide alternative treatment options.
- C. Seek a court order to proceed with the transfusion.
- D. Discuss the issue with the child.
Correct Answer: A
Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.