Nokea
A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?
- A. Position the client supine during feedings.
- B. Administer the feedings over 10 minutes.
- C. Elevate the head of the bed during feedings.
- D. Place the client in a lateral position after feedings.
Correct Answer: C
Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.
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A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification band
- B. Verify the provider's prescription
- C. Prime the IV tubing with 0.9% sodium chloride
- D. Obtain the client's vital signs
Correct Answer: A
Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.
A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 60/min
- B. Respiratory rate of 16/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1.5 kg (3.3 lb) in 24 hours
Correct Answer: D
Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.
A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?
- A. Administer oxygen and assess the client's response.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the IV infusion.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.
A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Pain rating of 4 on a scale of 0 to 10
- C. Respiratory rate of 10/min
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.