Nokea
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
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Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?
- A. Administer an analgesic as ordered.
- B. Notify the physician.
- C. Apply a cold pack to the surgical site.
- D. Assess the surgical site for signs of infection.
Correct Answer: D
Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- A. Elevate the client's right arm on pillows
- B. Place the client's right arm in a dependent sling
- C. Keep the client's right arm on the bed beside her
- D. Place the client's right arm across her body
Correct Answer: A
Rationale: Elevating the arm on pillows reduces edema and promotes lymphatic drainage post-mastectomy, aiding recovery.
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.
Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?
- A. decreased or absent pedal pulses with cool or cold foot
- B. the presence of stasis ulcers over the medial malleolus
- C. skin atrophy and pallor with elevation of the affected leg
- D. decreased circumference in the affected leg due to venous constriction
Correct Answer: B
Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.