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The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?
- A. The suction gauge reads low intermittent suction.
- B. The client indicates that pain is a 3 on a scale of 1 to 10.
- C. The distal end of the NG tube is pinned to the client's gown.
- D. The client denies nausea and has 250 mL of fluid in the suction collection container.
Correct Answer: D
Rationale: An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The gastrointestinal tract lacks peristaltic activity as a result of manipulation during surgery. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is functioning properly. Although the nurse makes pertinent observations of the tube to ensure that it is secure and properly connected to suction, the client is assessed for the effect. A pain indicator of 3 is an expected finding in a postoperative client.
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The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
- A. Cola
- B. Coffee
- C. Chocolate milk
- D. Cranberry juice
Correct Answer: D
Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?
- A. Nausea
- B. Heartburn
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Trimethobenzamide is an antiemetic agent that is used for the treatment of nausea and vomiting. The medication is not used to treat heartburn, constipation, or abdominal pain.
The clinic nurse is observing a student perform a complete physical assessment on a client. During the respiratory assessment, the clinic nurse determines that the student is using which physical assessment technique?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: C
Rationale: To perform percussion, the nurse places the middle finger of the nondominant hand against the body's surface. The tip of the middle finger of the dominant hand strikes the top of the middle finger of the nondominant hand. Palpation is performed using the sense of touch. Inspection is the process of observation. Auscultation involves listening to the sounds produced by the body.
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
- A. Weight loss of 4 ounces and dry, peeling skin
- B. Blood glucose level of 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) before the last feeding
- C. Breast-feeding for 20 minutes or more, with strong sucking
- D. High-pitched cry, drinking 10 to 15mL of formula per feeding
Correct Answer: D
Rationale: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
The nurse instructs a parent regarding the appropriate actions to take when the toddler has a temper tantrum. Which statement by the parent indicates a successful outcome of the teaching?
- A. I will ignore the tantrums as long as there is no physical danger.
- B. I will give frequent reminders that only bad children have tantrums.
- C. I will send my child to a room alone for 10 minutes after every tantrum.
- D. I will reward my child with candy at the end of each day without a tantrum.
Correct Answer: A
Rationale: Ignoring a negative attention-seeking behavior is considered the best way to extinguish it, provided that the child is safe from injury. Option 2 is untrue and negative. Option 3 gives attention to the tantrum and also exceeds the recommended time of 1 minute per year of age for a time-out. Providing candy for rewards is unhealthy and unlikely to be effective at the end of the day.