Nokea
As adult is admitted with bleeding esophageal varices, and a triple-lumen nasogastric tube is inserted and the balloons inflated. What should the nurse keep at the bedside because the client has this tube?
- A. Adhesive tape
- B. A syringe with water
- C. Scissors
- D. A clamp
Correct Answer: C
Rationale: Scissors are kept at the bedside to cut and release the tube if the balloons cause airway obstruction or excessive pressure, a critical safety measure for triple-lumen tubes like the Sengstaken-Blakemore.
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A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?
- A. Encourage the parents to openly discuss the child's questions
- B. Notify the health care provider about the child's questions
- C. Remind the child that everyone is trying to help the child get better
- D. Tell the child to ask the parents the questions about death
Correct Answer: A
Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.
The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?
- A. reports of intermittent nausea
- B. crackles in the lung bases bilaterally
- C. 1+ pitting edema of the ankles and feet bilaterally
- D. blood pressure of 108/88 mm Hg and heart rate of 72/min
Correct Answer: B
Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.
Which of the following cutaneous manifestations is associated with Lyme disease?
- A. Annular rash
- B. Papular crusts
- C. Bullae
- D. Plaques
Correct Answer: A
Rationale: Lyme disease is characterized by an annular (erythema migrans) rash, often with a bull's-eye appearance, at the site of the tick bite.
The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.