Nokea
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)
- A. Pinch and withdraw the tube.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Apply clean gloves.
Correct Answer: E,B,C,D,A
Rationale: E: Gloves first. B: Disconnect suction. C: Instill air clears tube. D: Deep breath aids removal. A: Pinch and withdraw.
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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.
A nurse is contributing to planning an interprofessional conference for a client who reports concerns about their BMI of 30. Which of the following members of the interprofessional team should the nurse include?
- A. Occupational therapist
- B. Pharmacist
- C. Dietician
- D. Spiritual support personnel
Correct Answer: C
Rationale: A dietician addresses BMI concerns through nutritional planning.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. I can name my sibling as my designee in my durable power of attorney for health care.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: B
Rationale: Naming a designee is a key component of a durable power of attorney.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Open the outside cover of the sterile kit and remove the dust cover
- B. Grasp the outermost flap of the sterile kit while opening away from the body.
- C. Prepare a dry work surface above the waist level
- D. Open the innermost lower flap of the sterile kit while standing away from the sterile field
- E. Open each side flap of the sterile kit individually while pulling to the side
Correct Answer: C, A, B, D, E
Rationale: Sequence maintains sterility: prepare surface, open kit, unfold flaps systematically.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place a pillow between the client's legs prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the client's arms above her head prior to logrolling.
- D. Place the bed in the lowest position before logrolling the client.
Correct Answer: A
Rationale: A pillow between legs maintains spinal alignment during logrolling post-laminectomy.