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A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr. after the feeding.
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding.
Correct Answer: A
Rationale: Head elevation for 1 hour reduces aspiration risk, critical for jejunostomy care. Other options are incorrect or unnecessary.
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A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
- A. Take iron supplements between meals for maximum absorption.
- B. Mix iron supplements with milk to prevent staining of the teeth.
- C. Reduce gastric distress by taking iron supplements with an antacid.
- D. Check for orange-colored stools after 4 days of treatment.
Correct Answer: A
Rationale: Iron supplements treat anemia by boosting hemoglobin, but absorption and side effects guide administration. Option A is correct taking iron between meals maximizes absorption since food, especially calcium or fiber, can bind iron, reducing bioavailability. Gastric acid enhances uptake, so an empty stomach is ideal, though some tolerate it with a small snack if irritation occurs. Option B is wrong milk's calcium inhibits absorption and doesn't prevent teeth staining (diluting in juice does). Option C is incorrect antacids raise stomach pH, decreasing iron absorption, and may worsen deficiency. Option D is false iron typically causes black, not orange, stools due to unabsorbed iron oxidation; orange stools could signal another issue. Teaching about between-meal dosing empowers the client to optimize therapy, manage side effects (like constipation or nausea), and monitor for expected changes (e.g., darker stools), ensuring effective anemia treatment.
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
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A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
- A. Place the client's bed in reverse Trendelenburg position.
- B. Massage the affected extremity every 4 hr.
- C. Apply cold compresses to the affected extremity.
- D. Measure the calf of the affected extremity each shift.
- E. Elevate the leg.
- F. Apply warm compresses.
- G. Administer heparin.
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
- A. Instruct the client to tilt their head back to facilitate swallowing
- B. Encourage the client to use a straw.
- C. Provide oral care before meals.
- D. Schedule physical therapy directly before meals.
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
- A. Pull the fire alarm panel.
- B. Obtain a fire extinguisher.
- C. Remove the client from the room.
- D. Close the door to the client's room.
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.