Nokea
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.
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A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?
- A. decreased or absent pedal pulses with cool or cold foot
- B. the presence of stasis ulcers over the medial malleolus
- C. skin atrophy and pallor with elevation of the affected leg
- D. decreased circumference in the affected leg due to venous constriction
Correct Answer: B
Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- A. Elevate the client's right arm on pillows
- B. Place the client's right arm in a dependent sling
- C. Keep the client's right arm on the bed beside her
- D. Place the client's right arm across her body
Correct Answer: A
Rationale: Elevating the arm on pillows reduces edema and promotes lymphatic drainage post-mastectomy, aiding recovery.