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The doctor has ordered nasogastric feedings for an elderly client with dysphagia. Prior to administering a tube feeding, the nurse should:
- A. Discard any aspirant and begin the tube feeding.
- B. Check the pH of the aspirant.
- C. Connect the tubing to suction.
- D. Mix the feeding with 200 mL of water.
Correct Answer: B
Rationale: Checking the pH of gastric aspirant confirms tube placement in the stomach (pH <5). Discarding aspirant risks fluid loss, suction is not routine, and mixing with water dilutes the feeding.
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A 35-year-old woman one-day postpartum receiving butorphanol tartrate (Stadol) 1 mg IM.
Which of the following actions is MOST important for the nurse to take after administering the medication?
- A. Observe the woman for sedation.
- B. Monitor the vital signs.
- C. Assess for visual disturbances.
- D. Evaluate fluid status.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice and how it relates to Stadol. (1) causes sedation, but not most important (2) correct-decreases rate and depth of respirations (3) diplopia and blurred vision are side effects, but not most important (4) not side effect of medication
The nurse is caring for a client who is receiving a continuous IV infusion of midazolam (Versed) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min
- B. Blood pressure of 100/60 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 90%
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious midazolam side effect. Options A, B, and C are acceptable: respiratory rate is low but stable, BP is mildly low, and heart rate is normal.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
- A. What symptoms should the nurse expect in a client with type I diabetes and a blood sugar of 50 mg/dL?
- B. Confused with cold, clammy skin and a pulse of 110.
- C. Lethargic with hot, dry skin and rapid, deep respirations.
- D. Alert and cooperative with a BP of 130/80 and respirations of 1
- E. Short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
The nurse is caring for a client with a history of type 2 diabetes who is receiving insulin aspart (NovoLog) 10 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 80 mg/dL.
- B. Heart rate of 90 bpm.
- C. Sweating and shakiness.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Sweating and shakiness indicate hypoglycemia, a serious complication of insulin aspart, requiring immediate treatment with carbohydrates. Options A, B, and D are less concerning: glucose 80 mg/dL is normal, heart rate 90 bpm and blood pressure 130/80 mmHg are stable.
A registered nurse (RN) asks the licensed practical nurse (LPN) to hang blood on a client. What is the best response by the LPN?
- A. Carefully check the order and the client identification and hang the unit if all is in order.
- B. Ask the RN to verify the order and then administer as ordered.
- C. Hang the blood after taking baseline vital signs.
- D. Refuse to administer the blood.
Correct Answer: D
Rationale: LPN scope of practice typically excludes initiating blood transfusions due to the need for specialized monitoring, requiring RN administration.