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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: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.
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A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Administer the medication with an antacid.
- B. Instruct the client to expect increased hair growth.
- C. Withhold the medication if the systolic blood pressure is less than 90 mm Hg
- D. Request a dosage increase if the apical heart rate is less than 60/min.
- E. Monitor for weight gain.
- F. Check respiratory rate.
- G. Administer with food.
Correct Answer: C
Rationale: Propranolol, a beta-blocker, should be withheld if BP is low to avoid hypotension; antacids don't interact, and hair growth isn't an effect.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
A nurse is reinforcing teaching for a client who was admitted with an exacerbation of COPD. Which of the following should the nurse include in the client teaching?
- A. You should consume small, frequent meals each day.
- B. You should decrease your caloric intake by 200 calories per day.
- C. You should increase your oxygen to 5 liters per minute if you have shortness of breath.
- D. You should discontinue your prednisone when your symptoms improve.
Correct Answer: A
Rationale: Small, frequent meals reduce diaphragm pressure and breathing effort in COPD. Caloric reduction isn't advised, oxygen adjustments need orders, and prednisone requires tapering.
A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 10
Rationale: Calculation: (25 mg / 12.5 mg) × 5 mL = 10 mL. This delivers the prescribed dose accurately.