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The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).
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A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?
- A. Mild nausea after taking the medication.
- B. Gingival hyperplasia and rash.
- C. Slight drowsiness in the morning.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention
The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be:
- A. Yes, you should be able to swim again, even with the colostomy.'
- B. You should avoid immersing the colostomy in water.'
- C. No, you should avoid getting the colostomy wet.'
- D. Don't worry about that. You will be able to live just like you did before.'
Correct Answer: A
Rationale: Swimming is possible with a colostomy if proper precautions, like a waterproof seal, are used to protect the stoma.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.
The nurse is on a memory care unit. A client insists on leaving to go home. Which of the following should the nurse do?
- A. review the reality orientation board in the client's room
- B. take the client to the activity room to interact with others
- C. contact the client's primary health care provider for a medication order
- D. provide the client with a glass of milk and a sandwich
Correct Answer: B
Rationale: Redirecting the client to a social activity can help distract from the desire to leave and promote engagement, which is appropriate for a client with memory issues.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.