Nokea
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
- A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.
- B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.
- C. Assist the client out of bed to sit upright in a chair for 1 hour.
- D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.
Correct Answer: C
Rationale: Sitting upright in a chair for 1 hour after a bolus tube feeding minimizes aspiration risk by promoting gastric emptying and reducing reflux.
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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.
A 62-year-old Chinese man is admitted with multiple injuries from a motor vehicle accident. He complains of severe pain and requests frequent medication. One of the assistive nursing personnel expresses surprise, saying, "I thought Asian people were very stoic about pain." Which is the nurse's best response about pain?
- A. Expression and perception of pain vary widely from person to person.
- B. Tolerance of pain is the same in all people.
- C. Tolerance of pain is determined by a person's genetic makeup.
- D. Pain perception is the same in all people.
Correct Answer: A
Rationale: Pain expression and perception vary individually due to cultural, personal, and situational factors, countering the stereotype. Pain tolerance and perception are not uniform or solely genetic.
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a posttest about the procedure.
Correct Answer: A
Rationale: The ability to perform the insulin injection safely and correctly demonstrates mastery of the skill, which is the best indicator of learning.
Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient?
- A. Teaching the client diaphragmatic breathing techniques.
- B. Administering cough suppressants as ordered.
- C. Teaching and encouraging pursed-lip breathing.
- D. Placing the client in a low semi-Fowler's position.
Correct Answer: C
Rationale: Pursed-lip breathing helps prolong exhalation, reducing air trapping and improving respiratory efficiency in clients with metastatic lung cancer.
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.