Nokea
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
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A nurse is planning care for a client who has undergone cardiac catheterization through the femoral artery. Which of the following actions should the nurse plan to take?
- A. Instruct the client to perform range-of-motion exercises to his lower extremities.
- B. Ambulate the client 1 hour following the procedure.
- C. Restrict the client's fluid intake.
- D. Assess the color, temperature, and pulse in the affected extremity.
Correct Answer: D
Rationale: Assessing the extremity monitors for vascular complications like bleeding or occlusion post-catheterization.
A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
- A. Profuse vomiting with fecal odor
- B. Epigastric abdominal distention
- C. Intermittent abdominal cramping
- D. Ribbon-like stools or diarrhea
- E. Metabolic acidosis
- F. Severe fluid and electrolyte imbalance
Correct Answer: A,B,C,D,E,F
Rationale: All are potential findings in LBO due to mechanical obstruction, bacterial overgrowth, and fluid shifts.
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
- A. Instruct the client to lean forward.
- B. Ask the client to extend the arms.
- C. Dorsiflex the client's foot.
- D. Measure the abdominal girth.
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Troponin
- B. Aspartate aminotransferase (AST)
- C. Serum amylase
- D. Unconjugated bilirubin
Correct Answer: A
Rationale: Troponin rises within 3-12 hours post-MI and is the most specific marker for myocardial injury.
A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
- A. Administer antiemetics as needed.
- B. Administer analgesics as needed.
- C. NPO (nothing by mouth) until pain-free.
- D. Monitor blood glucose and provide insulin as needed.
- E. Side-lying or fetal position.
- F. Monitor hydration status.
Correct Answer: A,B,C,D,F
Rationale: These interventions address pain management, pancreatic rest, glucose control, and hydration in acute pancreatitis.