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A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
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A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead w/the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.
Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?
- A. A word she whispers 30cm from his ear
- B. A number she traces on the palm of his hand
- C. The vibration of a tuning fork she places on his foot
- D. A familiar object she places in his hand
Correct Answer: D
Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
- A. Apply petroleum jelly around the inside of the nares
- B. Remove the nasal cannula during mealtimes
- C. Check the position of the cannula often
- D. Report any nasal stuffiness, nausea, or fatigue
- E. Post 'no smoking' signs in a prominent location
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
- A. Mopping her floors
- B. Brushing the back of her hair
- C. Fastening her bra behind her back
- D. Reaching into a cabinet above her sink
Correct Answer: C
Rationale: The correct answer is C. Fastening her bra behind her back. Internal rotation of the shoulder is necessary for this activity as it involves reaching the arm behind the body. Mopping the floors (A) and brushing the back of her hair (B) primarily require shoulder abduction and flexion. Reaching into a cabinet above the sink (D) involves shoulder flexion and abduction, not internal rotation.