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A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
- A. During the admission process.
- B. As soon as the client's condition is stable.
- C. During the initial team conference.
- D. After consulting with the client's family.
Correct Answer: A
Rationale: Correct Answer: A. During the admission process.
Rationale: Discharge planning should start early to ensure a smooth transition. During admission, the nurse can assess the client's needs, resources, and support system. This allows time to address any potential barriers to discharge and create a comprehensive plan. Starting discharge planning later may lead to delays and inadequate preparation for the client's transition. Initiating discharge planning during the admission process promotes continuity of care and helps prevent readmissions.
Summary of Other Choices:
B: Waiting until the client's condition is stable may delay discharge planning and increase the risk of complications during the transition.
C: Waiting for the initial team conference may result in missed opportunities to address discharge needs promptly.
D: Involving the client's family is important, but discharge planning should start early to ensure all aspects of the plan are considered and implemented effectively.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
- A. Sodium 130 mEq/L
- B. Creatinine 1.0 mg/dL
- C. Sodium 135 mEq/L
- D. Potassium 5.4 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Sodium 130 mEq/L. A sodium level of 130 mEq/L is considered hyponatremia, which can indicate potential fluid imbalance or certain health conditions. The nurse should report this finding to the provider for further evaluation and intervention.
Choices B, C, and D fall within normal reference ranges for creatinine, sodium, and potassium levels, respectively. Therefore, they do not require immediate reporting.
In summary, the nurse should report a low sodium level (A) as it can be clinically significant, while the other choices are within normal limits and do not warrant immediate action.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Remove the outer cannula carefully during cleaning.
- B. Use tracheostomy covers when outdoors.
- C. Use sterile technique when performing tracheostomy care at home.
- D. Cleanse mist with full-strength hydrogen peroxide.
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is crucial to prevent infections and ensure the client's safety. Sterile technique involves maintaining a clean environment, using sterile gloves, and sterile supplies to reduce the risk of introducing harmful microorganisms. Removing the outer cannula during cleaning (A) can increase the risk of accidental dislodgement and should only be done when necessary by a healthcare professional. Tracheostomy covers (B) are used to provide warmth and moisture, not necessarily for infection control. Cleansing mist with full-strength hydrogen peroxide (D) is too harsh and can damage the skin and mucous membranes.
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
- A. Stir the needle to 15° before administration.
- B. Aspire the syringe prior to administration.
- C. Administer the medication to the abdomen.
- D. Massage the site following the injection.
Correct Answer: C
Rationale: Correct Answer: C - Administer the medication to the abdomen.
Rationale: Heparin is typically administered subcutaneously. The abdomen has a larger subcutaneous tissue area compared to other sites, allowing for better absorption and reducing the risk of tissue damage. Administering heparin in the abdomen also minimizes the risk of hitting blood vessels and nerves. It is important to rotate injection sites to prevent tissue damage and ensure consistent absorption.
Summary of other choices:
A: Stirring the needle to a specific angle is unnecessary and can increase the risk of needle breakage or improper administration.
B: Aspiration is not required for subcutaneous injections as it may cause unnecessary tissue trauma.
D: Massaging the site after injection can lead to bruising and discomfort.
E, F, G: Choices left blank as they are not relevant to the administration of heparin.