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A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water every 4 hr.
- B. Place the client in a supine position during feeding.
- C. Check for gastric residual volume every 4 hr.
- D. Keep the head of the bed elevated to at least 30 degrees.
Correct Answer: D
Rationale: Elevating the bed to 30-45 degrees reduces aspiration risk by promoting proper digestion. Flushing maintains patency, supine position increases risk, and residual checks monitor tolerance.
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A nurse is caring for a client who is postoperative following a bowel resection. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid coughing.
- C. Apply a warm compress to the incision site.
- D. Administer a diuretic every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like ileus and thromboembolism. Coughing aids lung function, warm compresses risk infection, and diuretics aren't routine.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Check the IV site for redness or swelling.
- B. Administer the chemotherapy through a peripheral IV line.
- C. Monitor the client's blood pressure every 4 hr.
- D. Instruct the client to avoid drinking water during infusion.
Correct Answer: A
Rationale: Checking for redness or swelling detects extravasation early, critical for chemotherapy safety. Central lines are preferred, blood pressure checks are routine, and hydration is encouraged.
A nurse is reinforcing teaching with a client who has a new prescription for gabapentin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a high-fat meal.
- B. I might feel sleepy while taking this medication.
- C. I need to avoid sunlight while taking this medication.
- D. I can stop taking this medication as soon as my pain goes away.
Correct Answer: B
Rationale: Gabapentin can cause drowsiness, reflecting understanding. Food intake is flexible, sunlight isn't a concern, and stopping needs tapering.
A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
- A. Administer aspirin if the client develops a fever.
- B. Initiate contact precautions for the client.
- C. Assign the client to a negative-pressure airflow room.
- D. Have visitors remain at least 0.91 m (3 feet. away from the client.
Correct Answer: C
Rationale: Varicella requires airborne precautions, including a negative-pressure room, to prevent spread. Aspirin risks Reye's syndrome, contact precautions alone are insufficient, and distance doesn't replace airborne measures.
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Keep the tablets in a dark, airtight container.
- B. Take one tablet every 15 min for chest pain.
- C. You might feel a tingling sensation under your tongue.
- D. You should swallow the tablet with water.
Correct Answer: C
Rationale: Nitroglycerin causes a tingling sensation, indicating absorption. Tablets are kept in dark containers, taken every 5 minutes for pain, and not swallowed.