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A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?
- A. Label the feeding bag with the date and time of the start of the feeding.
- B. Aspirate the client's stomach contents.
- C. Hang the feeding bag 30 cm (12 inches) above the client.
- D. Warm the feeding to room temperature.
Correct Answer: B
Rationale: Aspirating the client's stomach contents is the first action the nurse should take to confirm correct placement of the NG tube before administering feeding.
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A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?
- A. Lactated Ringer's
- B. 0.9% sodium chloride
- C. 3% sodium chloride
- D. Dextrose 10% in water
Correct Answer: D
Rationale: D10W provides glucose to prevent hypoglycemia when TPN is interrupted.
A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)
- A. Beta-blocking agent
- B. Diuretic
- C. Opioid analgesic
- D. Lactulose
- E. Sedative
Correct Answer: A,B,D
Rationale: Beta-blockers reduce portal pressure, diuretics manage ascites, and lactulose treats hepatic encephalopathy.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Determine if pain radiates to the left arm
- C. Check the client's blood pressure
- D. Auscultate heart tones
Correct Answer: A
Rationale: ECG is the primary diagnostic tool for MI, showing characteristic ST changes.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
- A. Test the drainage for the halo sign.
- B. Ask the client to blow his nose.
- C. Notify the physician.
- D. Suction the nostril.
Correct Answer: A
Rationale: Testing for the halo sign (glucose in drainage) helps identify CSF leakage which requires immediate intervention.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?
- A. Bubbling of the water in the water seal chamber with exhalation
- B. Crepitus in the area above and surrounding the insertion site
- C. Movement of the trachea toward the unaffected side
- D. Eyelets are not visible
Correct Answer: B
Rationale: Crepitus indicates subcutaneous emphysema, which requires immediate attention as it suggests air leaking into tissues.