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A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct Answer: C
Rationale: Crushed tablet medications should be dissolved in 15-30 mL of sterile water to ensure proper delivery through the NG tube.
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A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the nurse use?
- A. Numeric rating scale
- B. Behavioral indicators)
- C. Visual analog scale
- D. Faces pain scale
Correct Answer: B
Rationale: For clients with dementia who have difficulty communicating, behavioral indicators such as increased agitation and restlessness are effective methods for assessing pain.
A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?
- A. Have the client lie down after meals
- B. Encourage the client to speak while eating
- C. Have the client sit upright for 1 hour following meals
- D. Offer thin liquids with meals
Correct Answer: C
Rationale: Having the client sit upright for 1 hour after meals facilitates swallowing and reduces the risk of aspiration.
A nurse is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the nurse use?
- A. A wheelchair
- B. A stand-assist lift
- C. A transfer belt
- D. A slide board
Correct Answer: B
Rationale: A stand-assist lift is appropriate for patients who can bear partial weight and have upper body strength.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.