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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?
- A. Check gastric residual volume every 8 hours.
- B. Flush the tube with cold water every 4 hours.
- C. Position the client flat during feeding.
- D. Change the feeding bag every 72 hours.
Correct Answer: C
Rationale: Positioning the client with the head of the bed elevated during feeding reduces the risk of aspiration, a critical safety measure.
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A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
- A. Oranges
- B. Potatoes
- C. Grapes
- D. Corn
Correct Answer: C
Rationale: Grapes are correct. Whole grapes are a known choking hazard for toddlers due to their size and shape, which can easily obstruct the airway. They should be cut into smaller pieces to reduce the risk.
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1.0 mL
- B. 1.2 mL
- C. 1.5 mL
- D. 2.0 mL
Correct Answer: C
Rationale: The correct dose is 1.5 mL. To calculate: (60 mg / 50 mg) * 1.25 mL = 1.5 mL. This ensures the infant receives the prescribed 60 mg of ibuprofen.
A nurse is reinforcing teaching with a client who is scheduled for a parathyroid scan. Which of the following instructions should the nurse include?
- A. Avoid iodine-rich foods for 1 week before the scan.
- B. Fast for 12 hours before the scan.
- C. Expect to receive sedation.
- D. Remove all jewelry before the scan.
Correct Answer: D
Rationale: Removing all jewelry before a parathyroid scan prevents interference with the imaging process.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
A nurse is reinforcing teaching with a client who has a new prescription for a vaginal pessary. Which of the following instructions should the nurse include?
- A. Remove the pessary daily for cleaning.
- B. Leave the pessary in place for 3 months.
- C. Insert the pessary at bedtime.
- D. Report any vaginal discomfort.
Correct Answer: D
Rationale: Reporting vaginal discomfort ensures early detection of complications like irritation or infection from the pessary.