Nokea
A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?
- A. Placing the tube in warm water
- B. Hyperextending the head while inserting the tube
- C. Removing the tube if any resistance to insertion is met
- D. Asking the client to swallow as the tube is being advanced
Correct Answer: D
Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.
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After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will take a laxative every night before going to bed.
- B. I must increase my intake of dietary fiber and fluids.
- C. I shall only use salt when I am cooking my own food.
- D. I'll eat white bread to minimize gastrointestinal gas.
Correct Answer: B
Rationale: Choice B is the correct answer. Clients with PKD often experience constipation, which can be managed by increasing their intake of dietary fiber and fluids. This helps promote bowel regularity. Laxatives should be used cautiously and not as a routine solution. Choice A is incorrect as regular laxative use is not recommended. Choice C is incorrect as a low-salt diet is typically advised for clients with PKD, not just limiting salt while cooking. Choice D is incorrect as white bread is low in fiber and not beneficial for managing constipation, which is common in PKD.
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
- A. 85%
- B. 89%
- C. 95%
- D. 100%
Correct Answer: C
Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected oxygen saturation level is at least 95%. Oxygen saturation levels below 95% may indicate hypoxemia, which can compromise tissue perfusion and oxygen delivery to vital organs. Therefore, maintaining oxygen saturation above 95% is crucial to ensure adequate oxygenation post-surgery. Choices A, B, and D are incorrect as they represent oxygen saturation levels that are below the expected value for a client without a history of respiratory disease, which should be at least 95%.
After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP's performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?
- A. Selecting the female icon for all female clients and the male icon for all male clients
- B. Explaining to the client, 'This test measures the amount of urine in your bladder.'
- C. Applying ultrasound gel to the scanning head and cleaning it after use
- D. Taking at least two readings using the aiming icon to position the scanning head
Correct Answer: A
Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding. Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions. Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.
Which is a characteristic that distinguishes sulfonamides from other drugs used to treat bacterial infections?
- A. Sulfonamides are bactericidal.
- B. Sulfonamides are synthetic compounds.
- C. Sulfonamides have antifungal and antiviral properties.
- D. Sulfonamides increase bacterial synthesis of folic acid.
Correct Answer: B
Rationale: The characteristic that distinguishes sulfonamides from other drugs used to treat bacterial infections is that sulfonamides are synthetic compounds, not derived from biologic substances. Choice A is incorrect because sulfonamides are bacteriostatic, not bactericidal. Choice C is incorrect because sulfonamides do not have antifungal and antiviral properties. Choice D is incorrect because sulfonamides act by inhibiting bacterial synthesis of folic acid, not increasing it.
A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Nocturia
- B. Flank pain
- C. Increased abdominal girth
- D. B & C
Correct Answer: D
Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.