Nokea
Draw up prescribed amount of sterile solution ordered.
- A. 3, 2, 6, 1, 5, 4
- B. 5, 6, 1, 2, 3, 4
- C. 1, 5, 6, 3, 2, 4
- D. 6, 5, 1, 3, 2, 4
Correct Answer: D
Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.
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The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
A nurse is standing beside the patient’s bed. Nurse:How are you doing? Patient:I don’t feel good. Which element will the nurse identify as feedback?
- A. Nurse
- B. Patient
- C. How are you doing?
- D. I don’t feel good.
Correct Answer: D
Rationale: In communication, feedback is the response or message provided by the receiver to the sender. In this scenario, the nurse asks the patient, "How are you doing?" The patient's response, "I don't feel good," is the feedback. It is the patient's reaction and message returning to the nurse. The nurse, in this context, is the sender initiating the conversation, while the patient is the receiver providing the feedback in response to the nurse's inquiry. Therefore, the statement "I don't feel good" constitutes the feedback in this communication exchange.
A small-bore feeding tube is placed. Which technique will the nurse use tobestverify tube placement?
- A. X-ray
- B. pH testing
- C. Auscultation
- D. Aspiration of contents
Correct Answer: A
Rationale: At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. X-ray allows for direct visualization of the tube's placement within the gastrointestinal tract, ensuring it is correctly positioned in the stomach without any risk of inadvertent placement in the lungs, pharynx, or esophagus. This method provides a definitive confirmation of tube placement, which is crucial for patient safety during enteral feeding. While pH testing and aspiration of contents can be useful as supplementary methods, x-ray remains the gold standard for verifying tube placement due to its precision and accuracy. Auscultation, on the other hand, is no longer recommended as a reliable method for tube placement verification, as it may lead to misinterpretation of sounds and potential errors in placement assessment.
A nurse is asked how many kcal per gram fats provided. How should the nurse answer?
- A. 3
- B. 4
- C. 6
- D. 9
Correct Answer: D
Rationale: Fats, also known as lipids, are the most calorie-dense nutrient, providing 9 kcal per gram. This high calorie content is due to the structure of fats, which contain more carbon-hydrogen bonds, making them more energy-dense compared to carbohydrates and proteins. Carbohydrates and proteins, on the other hand, provide 4 kcal per gram each. This makes fats an important source of energy in the diet, but they should be consumed in moderation to maintain a healthy balance of nutrients.
A nurse is teaching a health class about colorectalcancer. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. A risk factor is smoking.
- B. A risk factor is high intake of animal fats or red meat.
- C. A warning sign is rectal bleeding.
- D. A warning sign is a sense of incomplete evacuation.
Correct Answer: A
Rationale: A. A risk factor is smoking: Smoking has been identified as a risk factor for colorectal cancer. It is important for the nurse to include this information during the teaching session to emphasize the importance of smoking cessation in reducing the risk of developing colorectal cancer.