Nokea
Prior to administering a tube feeding, the nurse obtains 50 mL of aspirant. The nurse should:
- A. Discard the aspirant and begin the tube feeding.
- B. Replace the aspirant and begin the tube feeding.
- C. Discard the aspirant and hold the tube feeding.
- D. Replace the aspirant and hold the tube feeding.
Correct Answer: B
Rationale: Replacing the aspirant prevents fluid/electrolyte loss, and feeding can proceed if pH confirms placement. Discarding aspirant risks dehydration, and holding the feeding is unnecessary unless placement is uncertain.
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A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
- A. Ataxia and coarse hand tremors
- B. Vomiting, diarrhea and lethargy
- C. Pruritus, rash and photosensitivity
- D. Electrolyte imbalance and cardiac arrhythmias
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.
The nurse is to change a dressing. Which is essential to do when opening the dressing set?
- A. Open the first flap away from the nurse.
- B. Open the first flap toward the nurse.
- C. Place the dressing set on a chair beside the bed.
- D. Place the dressing set on the client's bed.
Correct Answer: A
Rationale: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.
The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.
- A. I am going to join a walking program to lose excess weight.
- B. I may have dry mouth as a side effect from the oxybutynin.
- C. I really need caffeine to get myself going in the morning.
- D. I should perform Kegel exercises several times daily.
- E. I will void every 2 hours until I am having fewer accidents.
Correct Answer: A,B,D,E
Rationale: Weight loss (A) reduces bladder pressure, oxybutynin’s dry mouth side effect (B) is correct, Kegel exercises (D) strengthen pelvic floor muscles, and scheduled voiding (E) prevents urgency. Caffeine (C) irritates the bladder, worsening incontinence, indicating ineffective teaching.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.
A low-residue diet is ordered for an adult. The nurse knows that the client understands the diet when which menu is selected?
- A. Lettuce and tomato salad, steak sandwich, orange slices
- B. Gelatin salad, mashed potatoes, sliced chicken
- C. Corn casserole, pork chop, rice
- D. Broccoli, broiled fish, sesame seed roll
Correct Answer: B
Rationale: Gelatin, mashed potatoes, and sliced chicken are low-fiber, low-residue foods, suitable for the diet. Lettuce, corn, broccoli, and sesame seeds are high-fiber, increasing residue.