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. Auscultate for air insufflation.
- C. Request a chest x-ray.
- D. Check the pH level of gastric contents.
Correct Answer: C
Rationale: A chest x-ray is the gold standard for confirming feeding tube placement.
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A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Closing the client's eyes
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Removing dentures distorts facial appearance, requiring intervention.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Recheck the client's SaO2 level after having the client cough and clear their throat.
- B. Notify the charge nurse of the client's condition.
- C. Review the client's most recent SaO2 level in the medical record.
- D. Check the client's medical records to see which medications were recently admitted.
Correct Answer: A
Rationale: Rechecking SpO2 after clearing the airway rules out temporary obstruction as the cause.
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. Assign different nurses to provide care for clients each day.
- B. Restrict the number of visitors for clients.
- C. Offer the clients many choices regarding care.
- D. Turn on loud music in client care areas.
Correct Answer: B
Rationale: Restricting visitors reduces noise and stress in an acute care setting.
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 protrudes slightly from the abdomen.
- B. The stoma appears dark in color.
- C. The stoma bleeds lightly when touched.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: B
Rationale: A dark-colored stoma indicates potential ischemia or necrosis, requiring immediate reporting.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Room number
- D. Age
Correct Answer: A
Rationale: A photograph is a reliable identifier per safety standards.