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A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?
- A. Administer the feeding over 30 minutes
- B. Place the child in a supine position after the feeding
- C. Change the feeding bag and tubing every 3 days
- D. Warm the formula in a warm water bath before administration
Correct Answer: B
Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.
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When administering digoxin 0.125 mg PO to an adult client, for which of the following findings should the nurse report to the provider?
- A. Potassium level 4.2 mEq/L.
- B. Apical pulse 58/min
- C. Digoxin level 1 ng/mL
- D. Constipation for 2 days
Correct Answer: C
Rationale: Monitoring the digoxin level is crucial as it helps determine the drug's effectiveness and potential toxicity. A digoxin level of 1 ng/mL is within the therapeutic range. However, levels above this range can lead to toxicity, causing adverse effects like nausea, vomiting, visual disturbances, and dysrhythmias. Therefore, the nurse should report a digoxin level of 1 ng/mL to the provider for further evaluation and potential dose adjustment.
When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?
- A. Allow the client enough time to perform rituals
- B. Give the client autonomy in scheduling activities
- C. Discourage the client from exploring irrational fears
- D. Provide negative reinforcement for ritualistic behaviors
Correct Answer: A
Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.
When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?
- A. Psychologist
- B. Social worker
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.
A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
- A. Place the client's left arm on a pillow while he is sitting.
- B. Provide total care in assisting with the client's ADLs.
- C. Encourage mobility and avoid bed rest.
- D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.
Correct Answer: A
Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.
A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client.
- B. Evaluate the client's understanding of life-sustaining measures.
- C. Determine the client's preferences about post-mortem care.
- D. Request a conference with the client's family
Correct Answer: B
Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.