Nokea
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.
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Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.
Which of the following organs is most likely to suffer permanent damage from shock?
- A. The heart
- B. The skin
- C. The brain
- D. The kidneys
Correct Answer: D
Rationale: The kidneys are highly susceptible to permanent damage from shock due to reduced perfusion, leading to acute kidney injury.
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.