Nokea
After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
- A. What is the most appropriate nursing intervention for a client with a nasogastric tube who becomes nauseated with decreased gastric secretion flow?
- B. Irrigate the nasogastric tube with distilled water.
- C. Aspirate the gastric contents with a syringe.
- D. Administer an antiemetic medicine.
- E. Insert a new nasogastric tube.
Correct Answer: B
Rationale: Nausea and decreased flow suggest possible NG tube obstruction. Aspirating gastric contents with a syringe confirms tube placement (pH 0-4) and checks for blockages, addressing the cause of symptoms. Irrigation should use normal saline after placement confirmation, and antiemetics or tube replacement do not assess tube function.
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A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any eye pain.
- C. Use the drops every 4 hours.
- D. Avoid regular eye exams.
Correct Answer: B
Rationale: Eye pain may indicate a complication with latanoprost, requiring reporting. Options A, C, and D are incorrect.
A client who has clear lung sounds and unlabored breathing is receiving aminophylline IV.
Which of the following would be the MOST appropriate nursing action if the client's IV infiltrates?
- A. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
- B. Wait two hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
- C. Restart the IV and continue the previous medication schedule.
- D. Call the physician and recommend that the IV medications be changed to PO.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) continued IV medication may not be necessary based on the current assessment (2) physician should be notified if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) correct-before a new IV is started on this client, physician should be called and PO medications recommended
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration
The nurse is conducting a community group discussion on nutrition. One of the participants says to the nurse, 'I am a vegan. I have been told I might get pernicious anemia. How can I prevent that?' What should the nurse include when answering the client?
- A. She is not at risk for pernicious anemia because there are many nonmeat sources of vitamin B12.
- B. She is at risk of developing pernicious anemia, but taking a vitamin supplement that contains vitamin B12 should prevent it.
- C. She should see her physician and ask about getting monthly injections of vitamin B12 because she is a risk for pernicious anemia.
- D. She should be tested for an enzyme that produces vitamin B12. If she is deficient, she should be treated with daily injections.
Correct Answer: B
Rationale: Vegans lack dietary B12 (found in animal products), risking pernicious anemia. Oral B12 supplements can prevent deficiency, while injections or enzyme testing are unnecessary unless absorption issues exist.