Nokea
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
The FIRST nursing action should be to
- A. administer the PRN pain medication and an antiemetic.
- B. irrigate the nasogastric tube with normal saline.
- C. determine if the nasogastric tube is patent and draining.
- D. check the placement of the nasogastric tube by auscultation.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation
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Assessment findings the nurse could expect to find in the infant with biliary atresia are:
- A. Excessive drooling that requires frequent suctioning
- B. Pale, frothy stools, and poor weight gain
- C. Poor tissue turgor and weight loss
- D. Clay-colored stools and abdominal distention
Correct Answer: D
Rationale: Biliary atresia causes bile duct obstruction, leading to clay-colored stools and abdominal distention from liver enlargement, so D is correct. Answers A, B, and C are not specific to biliary atresia.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
The nurse is aware that Rh immune globulin (RhoGAM) is administered.
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
- A. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
- B. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs'.
- C. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
- D. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) if both mother and baby are Rh-negative, there is no problem (2) correct-RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when baby has a negative Coombs' Test (3) medication is not given if the mother has been sensitized by a previous pregnancy (4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy
A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client's greatest risk factors for osteoporosis?
- A. History of menopause at age 50
- B. Taking high doses of steroids for arthritis for many years
- C. Maintaining an inactive lifestyle for the past 10 years
- D. Drinking 2 glasses of red wine each day for the past 30 years
Correct Answer: B
Rationale: Taking high doses of steroids for arthritis for many years. The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.