Nokea
The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care?
- A. Inspect the insertion line at the naris prior to instilling formula.
- B. Elevate the head of the bed (HOB) after feeding the client.
- C. Place the client in the Sims position following each feeding.
- D. Change the dressing on the feeding tube every three (3) days.
Correct Answer: B
Rationale: Elevating HOB post-feeding (B) prevents aspiration in PEG clients. Naris inspection (A) applies to NG tubes, Sims position (C) is not standard, and dressings (D) are changed PRN.
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A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's?
- A. hearing
- B. mental status
- C. vitamin B6 level
- D. vision
Correct Answer: D
Rationale: This medication can cause inflammation of the optic nerve. Therefore, it is very important the nurse asks the patient about their vision. If the patient has blurred vision or reports a change in colors, the MD must be notified immediately.
Which nursing action is most appropriate immediately after the chest tube is removed from the client?
- A. Apply a sterile dressing and tape it securely.
- B. Request a chest X-ray to assess lung fields.
- C. Administer oxygen by nasal cannula.
- D. Encourage the client to cough vigorously.
Correct Answer: A
Rationale: Applying a sterile dressing taped securely prevents air entry into the pleural space and promotes healing post-chest tube removal.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
Which question is most important for the nurse to ask the client at this time?
- A. When did you last take your prescribed medications?
- B. Have you taken all your medications as prescribed?
- C. How many drug refills have you obtained?
- D. Have you experienced any drug side effects?
Correct Answer: B
Rationale: Asking if the client has taken all medications as prescribed assesses adherence, which is critical for tuberculosis treatment efficacy.
After levalbuterol hydrochloride (Xopenex) administration, which client symptom does the nurse evaluate as a side effect of the medication?
- A. Respiratory rate of 28 breaths/minute
- B. Heart rate of 96 beats/minute
- C. Blood pressure of 100/60 mm Hg
- D. Drowsiness
Correct Answer: B
Rationale: Levalbuterol, a beta-agonist, commonly causes an increased heart rate as a side effect due to its stimulatory effects.