Nokea
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
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A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect?
- A. Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds.
- B. Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.
- C. Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity.
- D. Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. The 1st-pass effect refers to the metabolism of a drug in the liver before it reaches systemic circulation.
2. Medications administered orally undergo first-pass metabolism in the liver, leading to potential inactivation.
3. Administering such meds through nonenteral routes (e.g., intravenous) bypasses the liver, avoiding inactivation.
4. Choice A discusses receptor activity, not related to the first-pass effect.
5. Choice C refers to drug elimination rate, not specific to the first-pass effect.
6. Choice D discusses safety margin and monitoring, not directly related to drug metabolism.
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
- A. Extremes in age
- B. Impaired circulation
- C. Impaired/suppressed immune system
- D. Malnutrition
- E. Poor wound care
Correct Answer: B, C
Rationale: The correct answers are B (Impaired circulation) and C (Impaired/suppressed immune system). Impaired circulation can lead to decreased oxygen and nutrient delivery to the wound site, hindering the healing process. In this case, the adolescent may have impaired circulation due to diabetes mellitus. An impaired/suppressed immune system can also delay wound healing by impairing the body's ability to fight off infection and promote tissue repair. The other options are not applicable in this scenario: A (Extremes in age) does not apply as the client is an adolescent; D (Malnutrition) is not indicated as the client is tolerating a regular diet; and E (Poor wound care) is not evident as the incision is well-approximated and free of redness, with only scant serous drainage.
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
- A. Place the client in semi-Fowler's position
- B. Have the client rest an arm across the abdomen
- C. Observe one full respiratory cycle before counting the rate
- D. Count the rate for one minute if it is regular
- E. Count & report any sighs the client demonstrates
Correct Answer: A, B, C
Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate. Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.