Nokea
After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?
- A. Remove the air from the solution bag
- B. Obtain a piston syringe and irrigation set
- C. Record the solution added as fluid intake
- D. Calculate the rate of flow of the solution
Correct Answer: B
Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.
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A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti-tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP?
- A. Pyridoxine with a B complex multivitamin
- B. Gentamicin 160 mg IM daily
- C. Rifampin 600 mg PO daily
- D. Isoniazid 300 mg PO daily
Correct Answer: B
Rationale: The correct answer is B: Gentamicin 160 mg IM daily. Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity, leading to ringing in the ears (tinnitus). This symptom should be reported to the HCP immediately, as it may indicate a need to adjust or discontinue the medication. Choice A, Pyridoxine with a B complex multivitamin, is not the cause of ototoxicity. Choices C and D, Rifampin and Isoniazid, are anti-tubercular medications but are not associated with causing ringing in the ears.
The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?
- A. Obtain emergency help
- B. Feel for a carotid pulse
- C. Bring a glucometer to the room
- D. Check the blood pressure
Correct Answer: A
Rationale: The correct answer is to instruct the UAP to obtain emergency help first. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.
In which condition is the 'butterfly rash' most commonly seen?
- A. Systemic lupus erythematosus
- B. Rheumatoid arthritis
- C. Psoriasis
- D. Dermatomyositis
Correct Answer: A
Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.
A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?
- A. Administer the prescribed analgesic and encourage participation after it takes effect.
- B. Reschedule the physical therapy session for later in the day.
- C. Explain the importance of physical therapy for recovery.
- D. Notify the physical therapist of the client's refusal.
Correct Answer: A
Rationale: Administering pain medication before physical therapy helps manage the pain, making it easier for the client to participate in the necessary exercises to improve recovery and prevent complications such as joint stiffness. Choice B is not the first step as addressing the pain should take precedence. Choice C is important but should come after managing the pain to facilitate participation. Choice D involves another healthcare provider and is not the immediate action needed in this situation.
During the immediate postoperative period following a total hip replacement, which intervention is most important for the nurse to implement?
- A. Encourage the client to use a walker or cane when ambulating
- B. Keep the client's hip aligned with knees abducted
- C. Teach the client to sit on the side of the bed before standing
- D. Monitor urinary flow via an indwelling catheter
Correct Answer: B
Rationale: Keeping the client's hip aligned with the knees abducted is crucial to prevent dislocation of the prosthesis, which is a priority immediately after total hip replacement surgery. This position helps maintain the stability of the new hip joint. Encouraging the client to use a walker or cane (Choice A) is important but not as critical as ensuring proper hip alignment. Teaching the client to sit on the side of the bed before standing (Choice C) is a good practice but not as essential as maintaining hip alignment. Monitoring urinary flow via an indwelling catheter (Choice D) is not directly related to preventing complications immediately after a total hip replacement.