Nokea
A nurse is preparing to insert a nasogastric tube (NGT) in a client. Which action should the nurse take first?
- A. Assess the client's history for nasal trauma or surgery
- B. Ask the client to cough and deep breathe.
- C. Measure the length of the tube to be inserted.
- D. Explain the procedure to the client and obtain consent.
Correct Answer: D
Rationale: The correct first action for the nurse to take when preparing to insert a nasogastric tube (NGT) in a client is to explain the procedure to the client and obtain consent. It is crucial to ensure that the client is informed about the procedure, understands it, and consents to it before proceeding. Assessing the client's history for nasal trauma or surgery (Choice A) is important but can be done after obtaining consent. Asking the client to cough and deep breathe (Choice B) is not directly related to the initial step of preparing for NGT insertion. Measuring the length of the tube to be inserted (Choice C) is a necessary step but should come after explaining the procedure and obtaining consent.
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In caring for a client receiving the aminoglycoside antibiotic gentamicin, what diagnostic test should the nurse prioritize monitoring?
- A. Urinalysis
- B. Serum creatinine
- C. Serum osmolarity
- D. Liver enzymes
Correct Answer: B
Rationale: The correct answer is B: Serum creatinine. Aminoglycosides, such as gentamicin, are known to cause nephrotoxicity, which can lead to kidney damage. Monitoring serum creatinine levels is crucial in assessing renal function and detecting any potential kidney problems early. Choices A, C, and D are incorrect because urinalysis primarily assesses urine composition, serum osmolarity measures the concentration of solutes in the blood, and liver enzymes are not directly impacted by aminoglycoside antibiotics like gentamicin.
The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Blood pressure of 110/70 mmHg
Correct Answer: C
Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value is most concerning?
- A. INR of 3.0
- B. Prothrombin time (PT) of 15 seconds
- C. Hemoglobin of 10 g/dl
- D. White blood cell count
Correct Answer: A
Rationale: An INR of 3.0 is most concerning in a client prescribed warfarin (Coumadin) as it indicates a high risk of bleeding, requiring immediate intervention. A high INR value suggests that the blood is taking longer to clot, putting the patient at an increased risk of hemorrhage. Prothrombin time (PT) measures how long it takes for blood to clot, but the specific value of 15 seconds is within the normal range. Hemoglobin of 10 g/dl indicates mild anemia and does not directly relate to the risk of bleeding associated with warfarin therapy. White blood cell count assesses immune function and infection risk, but it is not directly related to the anticoagulant effects of warfarin.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?
- A. Administer intravenous insulin as prescribed.
- B. Monitor the client's urine output.
- C. Administer intravenous fluids.
- D. Administer 50% dextrose IV push.
Correct Answer: A
Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.
The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?
- A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
- B. Stop the NGT feed and notify the healthcare provider
- C. Increase the NGT suction pressure
- D. Elevate the head of the bed
Correct Answer: A
Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.