Nokea
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
You may also like to solve these questions
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the client asks why water is necessary after the formula drains, the nurse should respond:
- A. Water helps clear the tube so it doesn't get clogged.
- B. Flushing helps make sure the tube stays in place.
- C. This will help you get enough fluids.
- D. Adding water makes the formula less concentrated.
Correct Answer: A
Rationale: The correct answer is A: Water helps clear the tube so it doesn't get clogged. Water is necessary after enteral feeding to flush the feeding tube and prevent clogging, ensuring proper delivery of nutrition. Flushing with water also prevents residue buildup and maintains tube patency. This action helps prevent complications such as tube occlusion, which can lead to inadequate delivery of feedings or discomfort for the client. Options B, C, and D are incorrect because the primary reason for flushing the tube with water is to prevent clogging and maintain tube patency, not to secure the tube, provide fluids, or adjust formula concentration.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is unlawfully restrained against their will. In this scenario, the nurse administering a sedative without the client's consent is considered an act of restraint, which restricts the client's freedom to leave. This action constitutes false imprisonment as the client is being detained without proper legal authority.
A: Assault involves the threat of harm or unwanted physical contact, which is not present in this situation.
C: Negligence refers to a failure to provide proper care or fulfill duties, which is not the case here.
D: Breach of confidentiality involves disclosing private information without consent, which is not relevant in this scenario.
In summary, the nurse committed false imprisonment by restricting the client's freedom of movement without legal justification.
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.