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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The nurse is caring for a client who has a hip fracture and is placed in Buck traction. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client on the affected side.
- B. Monitor the client for skin breakdown.
- C. Perform frequent neurovascular checks.
- D. Keep the affected extremity in a neutral position.
- E. Ensure that the client receives adequate pain relief.
Correct Answer: B,C,D,E
Rationale: Monitoring for skin breakdown (B), neurovascular checks (C), neutral positioning (D), and pain relief (E) are essential for Buck traction. Placing the client on the affected side (A) is incorrect as it may disrupt traction.
The nurse is observing a staff member talking with the parent of a pediatric client. The parent is crying and states, 'I do not know what to do about this situation with my child.' The staff member responds, 'I am sure you will do the right thing.' The nurse should recognize that the staff member's response
- A. expresses interest in the parent's concern
- B. demonstrates respect for the parent's privacy
- C. devalues the parent's feelings and gives false reassurance
- D. conveys empathy toward the parent and promotes self-confidence
Correct Answer: C
Rationale: The response (C) dismisses the parent's distress and provides false reassurance, lacking empathy. It does not express interest (A), respect privacy (B), or convey empathy (D).
The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?
- A. I should offer only two options when my child is choosing things like clothes or meals.
- B. I will need to advocate for an individualized educational plan for my child.
- C. My child will most likely outgrow this disorder in early adulthood, around age 20.
- D. When talking with my child, I should focus and not be multi-tasking.
Correct Answer: C
Rationale: ADHD often persists into adulthood, so stating it will be outgrown by age 20 (C) is incorrect and requires intervention. Limiting choices (A), advocating for an IEP (B), and focusing during conversations (D) are appropriate.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The family of an 88-year-old woman who was admitted with severe dehydration says to the nurse, 'Why don't you just tie down her arms so she won't try to get out her IV?' What is the best response for the nurse to make?
- A. Ask the physician for an order to restrain the woman
- B. Explain to the family that restraints are not allowed in the hospital unless the doctor orders them
- C. Assess the client's mental status and safety needs
- D. Tell the family that they can restrain the client, but the nurse cannot
Correct Answer: C
Rationale: Assessing mental status and safety needs determines if restraints are necessary, prioritizing least restrictive measures.