Nokea
Gastrostomy tube was placed on the patient with terminal stage of throat cancer. Feeding is started today.
Prior to initiating the first gastrostomy feeding, the nurse should perform which of the following?
- A. Measure residual feeding.
- B. Palpate the abdomen.
- C. Assess for breath sounds.
- D. Flush the tube with 50 ml of NS.
Correct Answer: D
Rationale: Flushing the tube ensures patency before feeding, preventing blockages and ensuring safe administration.
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A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night.
- B. Practice monthly self-breast examination.
- C. Reduce stress.
- D. All of the above.
Correct Answer: D
Rationale: All listed actions—adequate sleep, self-breast exams, and stress reduction—contribute to cancer prevention by supporting immune function, early detection, and overall health. Health Promotion and Management
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation
Which teaching method is most effective when providing health care instructions to members of specific populations?
- A. teach-back
- B. video instructions
- C. written materials
- D. verbal explanation
Correct Answer: A
Rationale: The teach-back method ensures understanding by having patients repeat instructions in their own words, making it ideal for diverse populations with varying literacy levels. Video, written, or verbal methods may not confirm comprehension.
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
- A. obtain an order for a stool softener.
- B. administer packed RBCs, if ordered.
- C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
- D. dress venipuncture sites immediately to prevent infection.
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.