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A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?
- A. Hyperactive bowel sounds are present.
- B. Stomach contents are yellowish green in color.
- C. Aspirated stomach contents' pH measures 6.5.
- D. Residual volume of stomach contents measures 90 mL.
Correct Answer: C
Rationale: A pH of 6.5 suggests possible tube misplacement, requiring immediate reporting.
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A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension.
- B. BMI of 24.
- C. Type 1 diabetes mellitus.
- D. Family history of osteoporosis.
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular damage.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply
- A. Respiratory rate 10/min
- B. Pulse oximetry 88% on room air
- C. Blood pressure 99/46 mm Hg
- D. Morphine 10 mg administered subcutaneously
Correct Answer: A,B,D
Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?
- A. Apply clean gloves.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Pinch and withdraw the tube.
Correct Answer: A,B,C,D,E
Rationale: A: Gloves ensure hygiene. B: Disconnect suction. C: Air clears tube. D: Breath aids removal. E: Pinch prevents leakage.