Nokea
The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube?
- A. Pulling the tube back slightly
- B. Instructing the client to breathe slowly
- C. Continuing to advance the tube to the desired distance
- D. Checking the back of the pharynx using a tongue blade and flashlight
Correct Answer: C
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. The nurse should check the back of the pharynx using a tongue blade and flashlight to check for coiling and then pull the tube back slightly to prevent entrance into the larynx. Slow breathing helps the client relax to reduce the gag response.
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The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).
The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
- A. Rinsing it in sterile water
- B. Suctioning the client's airway
- C. Tapping it gently against a sterile basin
- D. Drying it with the provided pipe cleaners
Correct Answer: D
Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to find documented in the client's medical record? Select all that apply.
- A. Edema
- B. Anemia
- C. Polyuria
- D. Bradycardia
- E. Hypotension
- F. Osteoporosis
Correct Answer: A,B
Rationale: The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
- A. Prednisone orally
- B. Fludrocortisone orally
- C. Spironolactone intramuscularly
- D. Methylprednisolone sodium succinate intravenously
Correct Answer: D
Rationale: A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Spironolactone is a potassium-sparing diuretic.
After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands?
- A. Fever
- B. Neck pain
- C. Hoarseness
- D. Tingling around the mouth
Correct Answer: D
Rationale: The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Fever may be expected in the immediate postoperative period but is not an indication of damage to the parathyroid glands. However, if a fever persists the primary health care provider is notified. Neck pain and hoarseness are expected findings postoperatively.