Nokea
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?
- A. Verify the bilirubin level of the tube contents.
- B. Check the pH level of gastric contents.
- C. Auscultate for air insufflation.
- D. Request a chest x-ray.
Correct Answer: D
Rationale: A chest x-ray visually confirms tube placement, the most reliable method.
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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. The client's condition is stable right now.
- B. I will tell him you called.
- C. I cannot confirm or deny that we have a client by that name.
- D. He is here in the hospital, but I cannot tell you anything else.
Correct Answer: C
Rationale: This response protects confidentiality under HIPAA by not disclosing client presence.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma appears dark in color.
- D. The stoma bleeds lightly when touched.
Correct Answer: C
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Restrict the number of visitors for clients.
- B. Turn on loud music in client care areas.
- C. Offer the clients many choices regarding care.
- D. Assign different nurses to provide care for clients each day.
Correct Answer: A
Rationale: Restricting visitors minimizes noise and stress, promoting a healing environment.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Prevents skin breakdown. D: Ensures early detection of issues. E: Ensures proper fit and circulation.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.