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A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 4 hr.
- B. Flush the tube with water every 12 hr.
- C. Position the client supine during feeding.
- D. Change the feeding bag every 48 hr.
Correct Answer: A
Rationale: Checking residual volume every 4 hours assesses tolerance, preventing aspiration. Flushing is more frequent, supine positioning risks aspiration, and bags change every 24 hours.
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A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
- A. Maintain abduction of the client's residual limb with a pillow.
- B. Encourage the client to use the overbed trapeze.
- C. Caution the client to avoid a prone position while in bed.
- D. Keep a loose, absorbent dressing over the client's surgical site.
Correct Answer: B
Rationale: Using an overbed trapeze builds upper body strength, aiding independent repositioning. Abduction, avoiding prone positions, or loose dressings don't directly enhance mobility.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should keep my baby rear-facing in the car seat until she is 2 years old.
- B. I should position the car seat's retainer clip at the level of my baby's belly button.
- C. I should place my baby in the car seat at a 90-degree angle.
- D. I should enable the airbag when my baby is in the front seat of the car.
Correct Answer: A
Rationale: Rear-facing until age 2 maximizes safety per AAP guidelines. The retainer clip should be at armpit level, the angle at 45°, and airbags off for front-seat safety.
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.