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Nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which bed position is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's. This position helps prevent aspiration during enteral tube feedings by promoting proper digestion and reducing the risk of reflux. Semi-Fowler's allows gravity to assist in the movement of food through the gastrointestinal tract, decreasing the likelihood of regurgitation. Supine (A) can increase the risk of aspiration as it may cause reflux. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings due to increased risk of reflux and aspiration.
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Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.
A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.
Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group?
- A. I should keep feeding my son whole milk until he's 3 yo
- B. It's okay for me to give him a cup of apple juice with each meal
- C. I'll give my son about 2 tablespoons of each food at mealtimes
- D. My son loves popcorn, & I know it's better for him than sweets
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Giving a 2-year-old about 2 tablespoons of each food at mealtimes aligns with appropriate portion sizes for toddlers. This indicates an understanding of feeding guidelines for this age group, promoting balanced nutrition and preventing overfeeding.
Incorrect Answers:
A: Keeping a child on whole milk until 3 yo is not recommended due to the risk of excess fat intake.
B: Offering a cup of apple juice with each meal can lead to excessive sugar intake and may displace more nutritious foods.
D: Popcorn, while a better choice than sweets, may still pose a choking hazard for young children and may not provide balanced nutrition.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? Select all that apply.
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity during the fall, Time of the fall, and Trauma sustained. Therefore, the nurse should ask where the patient fell (A), what time the fall occurred (B), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to gather comprehensive information about the fall event. These questions help assess the circumstances surrounding the fall, potential risk factors, and any resulting injuries. Choices E and F are incorrect as they do not directly align with the components of the SPLATT acronym and may not provide relevant information for assessing the fall event.