Nokea
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
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Dual diagnosis indicates that there is a substance abuse problem as well as a
- A. cross addiction
- B. mental disorder
- C. disorder of any type
- D. medical problem
Correct Answer: B
Rationale: Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.
The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
- A. Report muscle weakness to the physician.
- B. Allow six months for the drug to take effect.
- C. Take the medication with fruit juice.
- D. Ask the doctor to perform a complete blood count prior to starting the medication.
Correct Answer: A
Rationale: The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer B is incorrect. The medication should be taken with water. Fruit juice, particularly grapefruit juice, can decrease the drug's effectiveness, so answer C is incorrect. Liver function studies, not a CBC, should be checked prior to beginning the medication, so answer D is incorrect.
The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: Urinary output of 30 ml per hour. This indicates adequate fluid replacement without suggesting overload.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.