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After insertion of a nasoenteric tube, the nurse should place the client in which position?
- A. Supine.
- B. Right side-lying.
- C. Semi-Fowler's.
- D. Upright in a bedside chair.
Correct Answer: C
Rationale: The semi-Fowler's position facilitates drainage and decompression via the nasoenteric tube while promoting comfort and preventing aspiration. Supine, right side-lying, or upright positions are less effective for this purpose. CN: Physiological adaptation; CL: Synthesize
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Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
The nurse is preparing to hang a new TPN bag. Which step is essential to prevent infection?
- A. Use clean gloves during setup.
- B. Verify the solution with another nurse.
- C. Change the tubing every 48 hours.
- D. Administer through a peripheral line.
Correct Answer: B
Rationale: Verifying the TPN solution with another nurse ensures accuracy and prevents errors that could lead to infection or other complications. Clean gloves are insufficient (sterile technique is needed), tubing change frequency varies, and TPN is typically given via a central line. CN: Safety and infection control; CL: Synthesize
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
- A. At least you will still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're lucky to have a wife to care for you.'
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.
To approach a deaf client, the nurse should do which of the following first?
- A. Knock on the room's door loudly.
- B. Close and open the vertical blinds rapidly.
- C. Talk while walking into the room.
- D. Get the client's attention.
Correct Answer: D
Rationale: Getting the client's attention first (e.g., by waving or tapping gently) ensures effective communication with a deaf client, as they may not hear auditory cues.
A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.