Nokea
If a client is to have a nasogastric (NG) tube inserted for intermittent feedings, which of the following is an appropriate task to delegate to unlicensed assistive personnel?
- A. Inserting the NG tube
- B. Verifying tube position
- C. Administer tube feedings
- D. Reposition a displaced NG tube
Correct Answer: C
Rationale: Administering tube feedings (C) can be delegated to unlicensed assistive personnel if trained, per facility policy. Inserting (A), verifying (B), and repositioning (D) require nursing judgment.
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The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
- A. Ineffective airway clearance
- B. Impaired gas exchange
- C. Fluid volume deficit
- D. Pain
Correct Answer: C
Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself.
- B. She pulls a toy behind her.
- C. She can build a tower of eight blocks.
- D. She can copy a horizontal or vertical line.
Correct Answer: B
Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?
- A. The medication can cause dental staining.
- B. The client will need to avoid a high-carbohydrate diet.
- C. The client will need a regularly scheduled blood work.
- D. The client will need a regularly scheduled blood work.
Correct Answer: C
Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
- A. Application of a short inclusive spica cast
- B. Stabilization with a plaster-of-Paris cast
- C. Surgery with Kirschner wire implantation
- D. A gauze dressing only
Correct Answer: B
Rationale: A plaster-of-Paris cast is typically used to stabilize foot fractures, ensuring proper alignment and healing.
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin
- B. Wash the skin with water and pat dry
- C. Cover the area with a petroleum gauze
- D. Apply an occlusive dressing to the site
Correct Answer: B
Rationale: Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.