Nokea
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
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A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Increased thirst (polydipsia) is a classic hyperglycemia symptom due to dehydration from glucose excretion.
A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed 45°
- B. Massage the client's bony prominences
- C. Provide the client with a high-calorie diet
- D. Reposition the client every 4 hrs
Correct Answer: C
Rationale: A high-calorie diet supports skin integrity and healing, reducing pressure injury risk.
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?
- A. Inflammation
- B. Remodeling phase
- C. Maturation
- D. Proliferation
Correct Answer: A
Rationale: Inflammation is the first phase of wound healing, initiating hemostasis and infection prevention.