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A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
- A. Tape the tube to the child's cheek.
- B. Attach an extension tube to the site's opening prior to use.
- C. Secure the tubing to the child's abdomen.
- D. Apply water-soluble lubricant to the site.
Correct Answer: C
Rationale: Securing the tube to the abdomen prevents dislodgement.
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The client has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin.
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
- A. You will suffer serious health issues if you don't take your medication.
- B. Have you considered how your decision to refuse medication will affect your family?
- C. I'd like to hear your thoughts about giving yourself this medication.
- D. Why don't you want to learn how to give yourself your medication?
Correct Answer: C
Rationale: Exploring the client's thoughts promotes understanding and respects autonomy.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
The client is disoriented and restless.
A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?
- A. Hypersomnia
- B. High cholesterol
- C. Urinary tract infection
- D. Amyloid plaque
Correct Answer: C
Rationale: Urinary tract infections are a common delirium risk factor, especially in older adults.
A nurse is providing care to a client who is preparing to undergo surgery. The client inquires about advance directives. Which of the following statements should the nurse make?
- A. Advance directives are the same as a consent form for health care treatment.
- B. Advance directives protect your right to make your own health care decisions.
- C. Advance directives must be approved by your lawyer.
- D. Advance directives are for clients who have life-threatening conditions.
Correct Answer: B
Rationale: Advance directives ensure client autonomy in health care decisions.
The preschooler has manifestations of respiratory syncytial virus.
A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?
- A. Administer fluconazole to the preschooler.
- B. Monitor the preschooler's urine for protein.
- C. Request an x-ray of the preschooler's neck.
- D. Initiate droplet precautions.
Correct Answer: D
Rationale: Droplet precautions prevent RSV transmission.