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 in a provider's office is reviewing the laboratory results of a group of clients. Which result is reportable?
- A. Herpes simplex
- B. Human papillomavirus
- C. Candidiasis
- D. Chlamydia
Correct Answer: D
Rationale: Chlamydia is a reportable sexually transmitted infection. Reporting cases of Chlamydia to the health department is crucial for disease surveillance, contact tracing, and implementing public health interventions. Herpes simplex, human papillomavirus, and candidiasis are not typically reportable infections, as they do not pose the same public health risks as Chlamydia.
A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?
- A. Lochia that is red and contains small clots.
- B. Fundus firm at the umbilicus.
- C. Fundus deviated to the right.
- D. Moderate perineal pain with swelling.
Correct Answer: C
Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).
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 preparing to administer a rectal suppository to a client. What action should the nurse take?
- A. Encourage the client to hold their breath as long as possible.
- B. Insert the suppository just past the anal sphincter.
- C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
- D. Place the client in a Sims' position before inserting the suppository.
Correct Answer: D
Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.