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A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
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A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Distorted perceptual field.
- B. Urinary frequency.
- C. Rapid speech.
Correct Answer: C
Rationale: The correct answer is C: Rapid speech. In clients with moderate anxiety, rapid speech is a common finding due to the increased arousal and nervousness associated with anxiety. The individual may talk quickly as a way to cope with their anxiety. Distorted perceptual field (A) is more indicative of severe anxiety or psychosis. Urinary frequency (B) is not a typical finding in moderate anxiety, unless there are underlying medical issues. Rapid speech (C) aligns with the increased arousal and restlessness seen in moderate anxiety.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.