Nokea
A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.
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The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.
- A. The organism that causes this condition is Corynebacterium diphtheriae.
- B. Vaccination is available starting at two months of age.
- C. Transmission of the cutaneous diphtheria is via direct contact with the infected person.
- D. Airborne precautions are required for individuals with pharyngeal diphtheria.
- E. Diphtheria is caused by a virus and is highly contagious.
Correct Answer: A,B,C,D
Rationale: Diphtheria is caused by Corynebacterium diphtheriae, vaccinated via DTaP at two months, cutaneous form spreads by contact, and pharyngeal diphtheria requires airborne precautions. It is bacterial, not viral.
The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.
The nurse recognizes which of the following treatments are alternative treatments for anxiety. Select all that apply.
- A. Black cohosh
- B. Ginger
- C. St. John's wort
- D. Kava
- E. Passion flower
Correct Answer: D,E
Rationale: Kava and passion flower are used for anxiety relief. Black cohosh treats menopausal symptoms, ginger aids nausea, and St. John’s wort is for depression.
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.
The nurse is preparing to restrain a client using soft-limb restraints. When initially restraining the client, it would be a priority for the nurse to
- A. Update the client's family on the use of the restraint.
- B. Obtain the client's pulse and blood pressure.
- C. Offer a snack and fluids.
- D. Inform the client the reason why they are being restrained.
Correct Answer: D
Rationale: Informing the client of the restraint’s reason promotes understanding and compliance, a priority for safety and ethics. Other actions are secondary.