Nokea
A nurse is preparing to administer a nasogastric (NG) tube feeding for a patient. What action should the nurse prioritize before initiating tube feeding?
- A. Verifying the NG tube placement by auscultating for bowel sounds
- B. Securing the NG tube to prevent dislodgement during feeding
- C. Checking the patency of the NG tube by aspirating gastric contents
- D. Elevating the head of the bed to a semi-Fowler's position
Correct Answer: C
Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.
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If a research study involves an intervention and "blinding" which research design is being referred to?
- A. Non-descriptive
- B. Experimental
- C. Phenomenological
- D. Descriptive
Correct Answer: B
Rationale: The research design being referred to in the question is an experimental design. An experimental study involves the manipulation of an independent variable, which is the intervention in this case, to determine its effect on a dependent variable. "Blinding" in research refers to the practice of withholding information about the intervention from certain individuals involved in the study, such as researchers, participants, or outcome assessors. Blinding is commonly used in experimental studies to reduce bias and ensure the integrity of the study results. This combination of intervention and blinding is a hallmark of experimental research designs.
Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
- A. Rapid progressive muscular atrophy.
- B. Ascending paralysis with ataxia .
- C. Hyperactive deep tendon reflexes
- D. Paresthesia and muscle weakness of upper body.
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.
Elmo asks the nurse to explain his condition (BPH) Which statements are CORRECT explanations by the nurse? I It blocks the urethra. II It obstructs the bladder. III. It spreads to other parts of the body. IV. It leads to urinary retention
- A. I and IV
- B. I, II and III
- C. II, III, and IV
- D. I and III
Correct Answer: A
Rationale: I. It blocks the urethra: Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate gland enlarges and can squeeze the urethra, leading to urinary symptoms such as difficulty urinating. This statement correctly explains one of the effects of BPH on the urinary system.
A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?
- A. Anterior uveitis
- B. Acute angle-closure glaucoma
- C. Endophthalmitis
- D. Corneal abrasion
Correct Answer: A
Rationale: The presentation described in the question is characteristic of anterior uveitis. Anterior uveitis is inflammation of the iris and ciliary body in the eye. Patients typically present with symptoms such as redness, pain, and photophobia. Slit-lamp examination findings include ciliary injection (redness and engorgement of blood vessels in the ciliary body), corneal edema (swelling of the cornea), and a mid-dilated pupil with a fixed reaction to light due to involvement of the iris muscles. These features differentiate anterior uveitis from other conditions. Treatment of anterior uveitis may involve topical steroids and cycloplegics to reduce inflammation and alleviate symptoms.
A woman in active labor is diagnosed with an amniotic fluid embolism. What is the priority nursing intervention?
- A. Administering oxygen via face mask
- B. Preparing for immediate cesarean section
- C. Initiating cardiopulmonary resuscitation (CPR)
- D. Inserting an indwelling urinary catheter
Correct Answer: C
Rationale: An amniotic fluid embolism is a rare and life-threatening complication during labor and delivery. It occurs when amniotic fluid or fetal cells enter the maternal circulation, triggering a rapid immune response that can lead to cardiovascular collapse and respiratory failure. The priority nursing intervention for a woman in active labor diagnosed with an amniotic fluid embolism is to initiate cardiopulmonary resuscitation (CPR) to support her vital functions and circulation. Providing immediate CPR can help sustain her until further medical interventions can be implemented. Administering oxygen and preparing for a cesarean section may be necessary but should occur after CPR is initiated to stabilize the woman's condition. Inserting an indwelling urinary catheter is not the priority in this emergency situation, as maintaining adequate cardiac and respiratory function takes precedence.