Nokea
The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client's discomfort?
- A. Reposition the tube in the nares.
- B. Irrigate the tube with a cool solution.
- C. Apply a water-soluble lubricant to the nares.
- D. Have the client change position more frequently.
Correct Answer: C
Rationale: Applying a water-soluble lubricant to the nares reduces irritation and discomfort caused by the NG tube.
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The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
- A. Keep the client on the right side for 2 hours.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Apply heat to the biopsy site.
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
- A. Injecting the medication via an infusion device
- B. Massaging the injection site after administration
- C. Injecting the medication 1 inch from the umbilicus
- D. Avoiding aspiration before administration of the medication
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.
A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?
- A. Yes, use the inhaler immediately for these symptoms.'
- B. No, this drug is a maintenance drug, not a rescue inhaler.'
- C. Use the inhaler 5 minutes before you exercise to prevent the wheezing.'
- D. This inhaler is for allergic rhinitis, not asthma.'
Correct Answer: B
Rationale: Salmeterol is a long-acting beta-agonist used for asthma maintenance, not for acute symptoms like wheezing during exercise. A rescue inhaler, such as albuterol, is appropriate for acute symptoms.
A client with a history of ulcerative colitis is prescribed sulfasalazine (Azulfidine). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid sun exposure.
- C. Stop the medication if diarrhea resolves.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Sulfasalazine can cause photosensitivity, so clients should avoid sun exposure.
A client with a history of depression is prescribed citalopram (Celexa). The nurse should instruct the client to:
- A. Report signs of serotonin syndrome.
- B. Take the medication at bedtime.
- C. Avoid high-fiber foods.
- D. Stop the medication if mood improves.
Correct Answer: A
Rationale: Citalopram can cause serotonin syndrome, requiring monitoring for agitation and tremors.