Nokea
The nurse is administering an intermittent tube feeding to a client through a nasogastric tube. Which of the following positions is optimal for tube feedings?
- A. The head of the bed is elevated to 45°.
- B. The head of the bed is elevated to 90°.
- C. The head of the bed is elevated to 30°.
- D. The head of the bed is flat with the client supine.
Correct Answer: A
Rationale: Elevating the head of the bed to 45° (A) during tube feedings reduces the risk of aspiration and promotes digestion. A 90° elevation (B) is excessive, 30° (C) is insufficient, and a flat position (D) increases aspiration risk.
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Which of the following roommates would be best for the client newly admitted with gastric resection?
- A. A client with Crohn's disease
- B. A client with pneumonia
- C. A client with gastritis
- D. A client with phlebitis
Correct Answer: C
Rationale: Gastritis aligns with gastric resection, posing no infection risk.
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
- D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to maintain alignment and traction.
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
- A. Loss of coordination
- B. Respiratory depression
- C. Visual hallucinations
- D. Tachycardia
Correct Answer: B
Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.
Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to 3 weeks?
- A. Total CK
- B. CK-MB
- C. Myoglobin
- D. Troponin T or I
Correct Answer: D
Rationale: Troponin T or I is highly specific for myocardial injury and can remain elevated for up to 2-3 weeks, making it the best marker for detecting cardiac damage.
Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.