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The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's stomach placement?
- A. Aspiration of tan-colored mucus
- B. Green aspirate with a pH of 3
- C. A swish auscultated with the injection of air
- D. Bubbling in a cup of NS when the end of the tube is placed in the cup
Correct Answer: B
Rationale: A green aspirate with a pH of 3 confirms gastric placement, as stomach contents are acidic and often green due to bile, providing the most reliable indicator.
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The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes during percussion sessions
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion create a vibration that helps loosen mucus in cystic fibrosis without causing injury.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
- A. Remove the mold and clean every week.
- B. Store the hearing aid in a warm place.
- C. Clean the lint from the hearing aid with a toothpick.
- D. Change the batteries weekly.
Correct Answer: A
Rationale: Regular cleaning of the hearing aid mold prevents wax buildup and ensures proper function.
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
- A. Notifying the doctor immediately
- B. Documenting the finding in the chart
- C. Decreasing the rate of IV fluids
- D. Administering vasopressive medication
Correct Answer: A
Rationale: Increased dilute urine suggests diabetes insipidus, a complication of pituitary surgery, requiring immediate physician notification for evaluation and treatment.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
A client receiving high doses of hydromorphone (Dilaudid®) develops acute respiratory depression with a drop in blood pressure. Which of the following treatments is most indicated?
- A. Naloxone
- B. Naproxen
- C. Flumazenil
- D. Nortriptyline
Correct Answer: A
Rationale: Naloxone (A) reverses opioid-induced respiratory depression. Naproxen (B), flumazenil (C), and nortriptyline (D) are not appropriate.