Nokea
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
- A. Turn the client on their side.
- B. Administer an analgesic.
- C. Administer antiemetic.
- D. Monitor the client's vital signs.
Correct Answer: A
Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.
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A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?
- A. Check for residual feeding contents.
- B. Administer the feeding through a large-bore syringe.
- C. Flush the tube with 10 mL of water after feeding.
- D. Administer the feeding at room temperature.
Correct Answer: C
Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.
A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should avoid using salt substitutes while taking this medication.
- B. I should take this medication with food to prevent nausea.
- C. I should increase my intake of potassium-rich foods while taking this medication.
- D. I should limit my fluid intake while taking this medication.
Correct Answer: A
Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.
A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?
- A. Place the mouthpiece in your mouth and blow out as quickly as you can.
- B. Exhale slowly into the mouthpiece over 5 seconds.
- C. Take a slow deep breath before blowing into the mouthpiece.
- D. Blow into the mouthpiece at a steady rate for 3 seconds.
Correct Answer: A
Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct Answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.
While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?
- A. Withhold all medications until after dialysis.
- B. Check the vascular access site for bleeding after dialysis.
- C. Rehydrate with dextrose 5% in water for hypotension.
- D. Give an antibiotic 30 minutes before dialysis.
Correct Answer: B
Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.