Nokea
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.
You may also like to solve these questions
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 +2:43 is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is transmitted through respiratory droplets from infected individuals. Droplet precautions involve wearing a mask when within 3 feet of the client to prevent the transmission of droplets. Contact precautions (Choice A) are for diseases spread through direct contact with the client or contaminated surfaces. Airborne precautions (Choice C) are for diseases that are transmitted through tiny particles that remain suspended in the air. Protective precautions (Choice D) are not a standard precaution type but rather a set of measures to protect immunocompromised clients from infections.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
- A. A lesion with uniform pigmentation
- B. New appearance of petechiae
- C. A mole with an asymmetrical appearance
- D. The presence of a papule
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. This is indicative of a potential skin malignancy such as melanoma. The asymmetry suggests irregular growth patterns, which can be a sign of cancerous cells. Other choices, such as A (lesion with uniform pigmentation), B (petechiae), and D (presence of a papule) are not specific indicators of skin malignancy. Lesions with uniform pigmentation are more likely to be benign. Petechiae are tiny red spots due to bleeding under the skin and are not typically associated with skin cancer. Papules are small raised bumps that can have various causes, not necessarily cancerous. Therefore, choice C is the most concerning finding for skin cancer based on asymmetry, prompting further evaluation and possible biopsy.
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.
Nurses' Notes: Day 1
Lactated Ringer'sat 100 mbhr infusing into a 20-guage IV catheter in left hand. IV ressing dry and Intact. IV site without redness or swelling. IV fluld infusing vl [ Place a pressure chessing over the IV site.
(03 Apply heat to the clients left hand.
Day2 [ start.a newIV inthe clent’s eft hand. IV site edematous. Skin surrounding catheter site taut blanched, and cool to touch. IV fluid not nfusing.
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
- A. Stop the IV infusion.
- B. Place a pressure dressing over the IV site.
- C. Apply heat to the client's left hand.
- D. Start a new IV in a different site.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The IV site is showing signs of infiltration (edematous, blanched, cool skin, IV fluid not infusing). Stopping the infusion prevents further harm.
B: Place a pressure dressing over the IV site - A pressure dressing helps reduce swelling and prevent further infiltration.
C: Apply heat to the client's left hand - Applying heat can help improve blood flow and absorption of any infiltrated fluids, aiding in the resolution of the issue.
Summary:
D: Starting a new IV in a different site would be premature without addressing the current issue of infiltration.
E, F, G: No other actions are indicated based on the information provided.