Nokea
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
- A. To remove gastric acid that might cause dyspepsia
- B. To identify delayed gastric emptying
- C. To confirm the placement of the NG tube
- D. To determine the client's electrolyte balance
Correct Answer: B
Rationale: Measuring residual identifies delayed gastric emptying, reducing aspiration risk.
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A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?
- A. Postoperative cognitive dysfunction
- B. Dementia
- C. Alzheimer's disease
- D. Postoperative delirium
Correct Answer: D
Rationale: Postoperative delirium causes acute, temporary confusion post-surgery, common in older adults.
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Increased thirst (polydipsia) is a classic hyperglycemia symptom due to dehydration from glucose excretion.
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Thirst indicates hyperglycemia as the body attempts to excrete excess glucose, causing dehydration.
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a significant risk from vomiting due to fluid and electrolyte loss.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.