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A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:
- A. Is unable to swallow foods by mouth
- B. Has a gastrointestinal obstruction
- C. Requires additional caloric intake to support healing
- D. Is at risk for aspiration
Correct Answer: A
Rationale: The correct answer is A: 'Is unable to swallow foods by mouth.' Tube feeding is prescribed when a client is unable to safely swallow food by mouth but has a functional gastrointestinal tract. Option B, 'Has a gastrointestinal obstruction,' is incorrect as tube feeding is not typically prescribed for this reason. Option C, 'Requires additional caloric intake to support healing,' is incorrect because tube feeding is specifically for clients who are unable to swallow. Option D, 'Is at risk for aspiration,' is also incorrect as tube feeding would not be the primary intervention for aspiration risk; other strategies to reduce aspiration risk would be implemented instead.
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The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?
- A. I will rotate my injection sites to avoid lipodystrophy.
- B. I will check my blood sugar before meals and at bedtime.
- C. I will use the same needle for 3 days if I keep it clean.
- D. I will keep my insulin refrigerated until I need it.
Correct Answer: C
Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.
A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:
- A. Solutes in the urine
- B. Bacteria in the urine
- C. pH level of the urine
- D. Glucose in the urine
Correct Answer: A
Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.
The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?
- A. Hypertension
- B. Bradycardia
- C. Hypoglycemia
- D. Weight gain
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.
A client has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family?
- A. Check the cord routinely for frays or tearing
- B. Use oxygen around open flames
- C. Store oxygen concentrator in a closet
- D. Wear synthetic clothing to prevent static electricity
Correct Answer: A
Rationale: The correct answer is to instruct the client and their family to check the cord routinely for frays or tearing. This is crucial to ensure the safety and proper function of the oxygen concentrator. Choice B is incorrect because oxygen should never be used around open flames due to the risk of fire. Choice C is also incorrect as oxygen cylinders or concentrators should not be stored in a closet due to ventilation and safety concerns. Choice D is incorrect because synthetic clothing can generate static electricity, which could pose a risk around oxygen equipment.
During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
- A. Face
- B. Feet
- C. Chest
- D. Arms
Correct Answer: A
Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.