Nokea
A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
- A. Instill 500 ml of solution through the NG tube
- B. Insert a large-bore NG tube
- C. Use a cold irrigation solution
- D. Instruct the client to lie on his right side
Correct Answer: B
Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.
You may also like to solve these questions
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).
A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?
- A. Withhold all medications until after dialysis.
- B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
- C. Check the vascular access site for bleeding after dialysis.
- D. Give an antibiotic 30 minutes before dialysis.
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.
A nurse is caring for a client who has cirrhosis. Which of the following laboratory findings should the nurse expect?
- A. Increased bilirubin levels
- B. Decreased albumin levels
- C. Increased prothrombin time
- D. Decreased serum glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Increased bilirubin levels are expected in clients with cirrhosis due to impaired liver function. Elevated bilirubin levels are commonly seen in cirrhosis as the liver's ability to process bilirubin is compromised. Decreased albumin levels and increased prothrombin time are also associated with cirrhosis, but the most specific finding related to liver dysfunction among the choices provided is increased bilirubin levels. Decreased serum glucose levels are not typically associated with cirrhosis.
A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?
- A. Obtain the client's vital signs.
- B. Ensure the client's IV access is patent.
- C. Prime the IV tubing with 0.9% sodium chloride.
- D. Verify the client's identity.
Correct Answer: D
Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.