Nokea
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed by at least 30 degrees.
- B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
- C. The LPN should discard the residual before administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.
You may also like to solve these questions
When removing a client's gown with an intravenous line, what should the nurse do?
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
- B. cut the gown with scissors
- C. thread the bag and tubing through the gown sleeve, keeping the line intact
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown
Correct Answer: C
Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.
During an annual physical exam, a client is diagnosed with Benign Prostatic Hyperplasia (BPH). This client is likely to have a consult with which type of physician?
- A. gynecologist
- B. physiatrist
- C. urologist
- D. proctologist
Correct Answer: C
Rationale: A client diagnosed with Benign Prostatic Hyperplasia (BPH) would typically have a consult with a urologist. Urologists specialize in urinary tract and prostatic diseases, making them the appropriate choice for managing BPH. A gynecologist focuses on diseases of the female reproductive tract, so they are not relevant in this case. A physiatrist specializes in rehabilitation care, which is not directly related to the treatment of BPH. A proctologist specializes in lower colonic digestive diseases, which are unrelated to BPH.
The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
- A. history of dizziness
- B. need for a wheelchair due to reduced mobility
- C. weakness and fatigue noted when climbing stairs
- D. intact recent and remote memory
Correct Answer: D
Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.
What is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct Answer: B
Rationale: Mammography is a diagnostic imaging technique specifically designed to detect tumors, cysts, or other abnormalities in breast tissue. It is not used to detect pain, edema, or epilepsy. Pain is a symptom, not a condition that mammography can detect. Edema refers to swelling and is not detectable through mammography. Epilepsy is a neurological disorder, not a condition detected by mammography.
What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?
- A. 5:01
- B. 1:05
- C. 15:02
- D. 2:15
Correct Answer: C
Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.