Nokea
After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 mL of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well.
- C. Monitor the client for nausea, vomiting, and abdominal distention.
- D. Turn the machine to high suction if the drainage is sluggish on low suction.
Correct Answer: C
Rationale: Monitoring for nausea, vomiting, and abdominal distention is essential to detect complications such as obstruction or ileus. Routine irrigation, repositioning, or increasing suction without medical orders is unsafe.
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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process
- D. Risk for impaired skin integrity related to vasospastic process
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
The nurse is precepting a newly hired nurse administering an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up?
- A. Prepares to administer the medication in the dorsogluteal.
- B. Prepares to insert the needle at a 90-degree angle.
- C. Uses isopropyl alcohol to clean the area prior to injection.
- D. Washes their hands before and after the procedure.
Correct Answer: A
Rationale: The dorsogluteal site is not recommended due to the risk of sciatic nerve injury.
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
- A. Sympathetic nervous system activation.
- B. Renin-angiotensin-aldosterone system activation.
- C. Myocardial hypertrophy.
- D. Natriuretic peptide release.
- E. Ventricular dilation.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (A), renin-angiotensin-aldosterone system (B), myocardial hypertrophy (C), natriuretic peptide release (D), and ventricular dilation (E) to compensate for reduced cardiac output.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.