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The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:
- A. Place the NG tube in warm water prior to insertion.
- B. Place the client in a supine position.
- C. Ask the client to swallow as the tube is advanced.
- D. Ask the client to hyper-extend his neck as the nurse begins to insert the tube.
Correct Answer: C
Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.
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Which statement, if made by the client, indicates a possible problem?
- A. I have a bowel movement every other day.'
- B. My stools recently are black.'
- C. Sometimes I have to strain when I go to the bathroom.'
- D. I usually have three stools a day.'
Correct Answer: B
Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?
- A. The nursing assistant places an abductor pillow between the client's legs while turning the client.
- B. The nursing assistant asks the client to put full weight on both legs while using the walker.
- C. The nursing assistant has a high extended bedside commode available for the client.
- D. The nursing assistant encourages the client to bathe herself.
Correct Answer: B
Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.