Nokea
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?
- A. A history of gastroesophageal reflux disease.
- B. Receiving a formula with high osmolarity.
- C. Sitting in a high-Fowler's position during the feeding.
- D. A residual of 65 mL 1 hour postprandial.
Correct Answer: A
Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.
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What is the most appropriate response when a client wants to discontinue dialysis?
- A. Ask the client why they want to discontinue.
- B. Instruct the client to focus on self-care.
- C. Offer to call the provider to cancel dialysis.
- D. Seek clarification and establish understanding.
Correct Answer: D
Rationale: When a client expresses the desire to discontinue dialysis, the most appropriate response is to seek clarification and establish understanding. This approach allows the healthcare provider to comprehend the client's concerns, provide support, and engage in a collaborative decision-making process. Choice A, asking the client why they want to discontinue, can be perceived as confrontational and may not effectively address the underlying reasons. Instructing the client to focus on self-care (Choice B) may overlook the client's autonomy and decision-making capacity. Offering to call the provider to cancel dialysis (Choice C) does not actively involve the client in the decision-making process or address their concerns adequately.
A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?
- A. Instruct the client to perform ankle pumps
- B. Administer anticoagulant therapy as prescribed
- C. Maintain the client in a prone position
- D. Encourage the client to ambulate as tolerated
Correct Answer: B
Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.
What are the nursing interventions for a patient with hypokalemia?
- A. Administer potassium supplements and monitor ECG
- B. Provide a high-sodium diet and monitor for hypertension
- C. Monitor for muscle weakness and provide dietary education
- D. Administer diuretics and provide oral fluids
Correct Answer: A
Rationale: The correct intervention for a patient with hypokalemia is to administer potassium supplements and monitor the ECG. Potassium supplements help correct the low potassium levels in the body, while ECG monitoring is essential to detect any cardiac arrhythmias associated with hypokalemia. Choice B is incorrect because a high-sodium diet would worsen hypokalemia by further depleting potassium levels. Choice C is incorrect as it only focuses on monitoring symptoms and providing dietary education, but does not address the immediate need to correct potassium levels. Choice D is also incorrect as administering diuretics would exacerbate hypokalemia by increasing potassium loss.
A client with diabetes is being discharged. What is an essential teaching point?
- A. Monitor blood sugar levels once a week
- B. Instruct the client to administer insulin before meals
- C. Teach the client to exercise regularly to maintain glucose control
- D. Administer oral hypoglycemics as needed
Correct Answer: B
Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?
- A. Prepare a new dose of insulin injection
- B. Administer the insulin as it is
- C. Wipe the needle with an alcohol swab
- D. Ask the provider for guidance
Correct Answer: A
Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.