Nokea
A nasogastric tube is ordered for an alert adult client. In addition to the tube and basin, what is essential for the nurse to have at the bedside during the procedure?
- A. A 5-cc syringe filled with water
- B. A glass filled with water and a straw
- C. A large clamp
- D. A container of sterile water
Correct Answer: B
Rationale: A glass of water with a straw helps the client swallow during nasogastric tube insertion, facilitating passage.
You may also like to solve these questions
The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching?
- A. If I notice any skin breakdown, I will call the HCP.
- B. I should drink only liquids until the colostomy starts to work.
- C. I should not take a tub bath until the HCP okays it.
- D. I should not drive or lift more than five (5) pounds.
Correct Answer: B
Rationale: A liquid-only diet is unnecessary; a regular diet can be resumed as tolerated unless otherwise specified, as colostomies begin functioning soon after surgery. The other statements reflect correct colostomy care.
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
- A. The client's Bernstein esophageal test was positive.
- B. The client's abdominal x-ray shows a hiatal hernia.
- C. The client's WBC count is 14,000/mm3.
- D. The client's hemoglobin is 13.8 g/dL.
Correct Answer: C
Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.
The client with liver problems asks the nurse, 'Why are my stools clay-colored?' On which scientific rationale should the nurse base the response?
- A. There is an increase in serum ammonia level.
- B. The liver is unable to excrete bilirubin.
- C. The liver is unable to metabolize fatty foods.
- D. A damaged liver cannot detoxify vitamins.
Correct Answer: B
Rationale: Clay-colored stools result from the liver’s inability to excrete bilirubin, which gives stool its brown color. Ammonia, fat metabolism, and vitamin detoxification are unrelated.
The nurse is caring for the client who has a temporary colostomy following surgery for colon cancer. The nurse assesses that the client’s colostomy bag is empty and that there has been no stool since surgery 24 hours ago. What should the nurse do?
- A. Call the surgeon immediately.
- B. Place the client left side-lying.
- C. Document these findings.
- D. Give a laxative medication.
Correct Answer: C
Rationale: The nurse should document the findings; the absence of stool is expected 24 hours postsurgery.
The nurse writes a problem 'low self-esteem' for a 16-year-old client diagnosed with anorexia. Which client goal should be included in the plan of care?
- A. The client will spend one (1) hour a day with the parents.
- B. The client eats 50% of the meals provided.
- C. Dietary will provide high-protein milk shakes (tid).
- D. The client will verbalize one positive attribute.
Correct Answer: D
Rationale: Verbalizing a positive attribute directly addresses low self-esteem by fostering positive self-perception. Time with parents, eating, and milk shakes are unrelated or nutritional.