Nokea
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
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A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
- A. Flush the tube with sterile sodium chloride solution every 2 hr.
- B. Change the feeding bag every 24 hr.
- C. Position the head of the client's bed at 15°.
- D. Check the gastric residual every 8 hr.
Correct Answer: B
Rationale: Changing the feeding bag every 24 hours prevents bacterial growth and infection, a standard practice for continuous feedings.
A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?
- A. Vitamin E
- B. Vitamin A
- C. Vitamin C
- D. Vitamin D
Correct Answer: C
Rationale: Vitamin C is water-soluble, requiring regular intake as it's not stored in the body.
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a common complication of vomiting due to significant fluid loss.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
- A. Assist the client to low Fowler's position.
- B. Test the pH of gastric aspirate.
- C. Discard any residual gastric contents.
- D. Warm the feeding solution to body temperature.
Correct Answer: B
Rationale: Testing gastric aspirate pH confirms NG tube placement in the stomach (pH 1-4).