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An adult has a nasogastric tube in place. Which nursing action will relieve discomfort in the nostril with the NG tube?
- A. Remove any tape and loosely pin the NG tube to his gown.
- B. Lubricate the NG tube with viscous lidocaine.
- C. Loop the NG tube to avoid pressure on the nares.
- D. Replace the NG tube with a smaller diameter tube.
Correct Answer: C
Rationale: Looping the NG tube reduces pressure on the nares, alleviating discomfort without compromising function.
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The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis?
- A. Eat a high-fiber diet.
- B. Increase fluid intake.
- C. Elevate the HOB after eating.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: A,B,D
Rationale: High-fiber diet, increased fluids, and regular exercise (e.g., walking) prevent constipation and reduce pressure in diverticula, lowering exacerbation risk. Elevating the HOB and antacids are unrelated to diverticulosis prevention.
The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles?
- A. The nurse repeats the information as indicated by the client's questions.
- B. The nurse teaches in one session all the information the client needs.
- C. The nurse uses a video so the client can hear the medical terms.
- D. The nurse waits until the client asks questions about the surgery.
Correct Answer: A
Rationale: Repeating information based on client questions respects adult learning principles by addressing the learner’s needs and reinforcing understanding. One-session teaching, videos, or waiting for questions are less interactive.
The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply.
- A. Ask the client about previous diet attempts.
- B. Refer the client to the dietitian.
- C. Discuss maintaining a sedentary lifestyle.
- D. Weigh the client.
- E. Assist the client to set a realistic weight loss goal.
Correct Answer: A,B,D,E
Rationale: Asking about diets, dietitian referral, weighing, and setting goals support nutritional management for obesity. A sedentary lifestyle is contraindicated.
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.