Nokea
A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?
- A. Discuss the risks of the procedure with the client.
- B. Confirm that the client is competent to sign for the procedure.
- C. Explain alternatives to the procedure to the client.
- D. Inform the client about what will occur during the procedure.
Correct Answer: B
Rationale: The nurse ensures the client's competence to consent, while the physician explains risks and procedures.
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A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
- A. Assist the client to low Fowler's position.
- B. Test the pH of gastric aspirate.
- C. Discard any residual gastric contents.
- D. Warm the feeding solution to body temperature.
Correct Answer: B
Rationale: Testing gastric aspirate pH confirms NG tube placement in the stomach (pH 1-4).
A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?
- A. Phosphorus
- B. Iron
- C. Magnesium
- D. Potassium
Correct Answer: B
Rationale: Iron in hemoglobin binds oxygen for transport in the blood.
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?
- A. Hold your breath for 7 seconds when using the incentive spirometer.
- B. Sit up at a 30-degree angle when using the incentive spirometer.
- C. Use the incentive spirometer once every 4 hours.
- D. Inhale through the incentive spirometer 10 times with each use.
Correct Answer: A
Rationale: Holding breath for up to 7 seconds maximizes lung expansion, a key goal of incentive spirometry.
A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.