Nokea
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
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The client has a chest tube attached to a portable water seal drainage system. Four hours after the chest tube is inserted, the nurse notes that there is no bubbling in the water seal compartment. What is the most likely explanation for this?
- A. The lung has reexpanded.
- B. There is an obstruction in the tubing coming from the pleural cavity.
- C. There is an air leak in the drainage system.
- D. The suction is not turned on.
Correct Answer: A
Rationale: No bubbling in the water seal four hours post-insertion suggests the lung has reexpanded, resolving the pneumothorax. Obstruction, air leaks, or inactive suction would typically cause other signs.
A client with a diagnosis of acoustic neuroma asks the nurse to explain what is wrong with his hearing. The nurse's response is based on the knowledge that an acoustic neuroma is:
- A. A malignant tumor of the inner ear with rapid metastasis
- B. A malignant tumor of the fifth cranial nerve that affects hearing and chewing
- C. A benign tumor of the auditory nerve that may cause destruction to the cerebellum
- D. A highly vascular benign lesion of the middle ear that arises from the jugular vein
Correct Answer: C
Rationale: An acoustic neuroma is a benign tumor of the eighth cranial (auditory) nerve that can affect hearing and balance and may cause compression of nearby structures, such as the cerebellum. Answer A is incorrect because acoustic neuromas are benign, not malignant. Answer B is incorrect because it involves the fifth cranial nerve, which is unrelated. Answer D refers to a glomus tumor, not an acoustic neuroma.
All of the following women are seen in the physician's office. Which is at greatest risk for preterm labor?
- A. A primigravida who has gained 30 lb during her pregnancy
- B. A 35-year-old carrying a small baby
- C. A 21-year-old pregnant with twins
- D. A 40-year-old who has four other children
Correct Answer: C
Rationale: Multiple gestation, such as twins, significantly increases preterm labor risk due to uterine overdistension, making the 21-year-old the highest risk.
The nurse is assessing a client who had surgery 12 hours ago and is receiving IV morphine for incisional pain. It would require immediate follow-up if the client
- A. Has a blood pressure of 106/68 mm Hg
- B. Falls asleep while speaking with the nurse
- C. Reports burning at the IV site during administration of the medication
- D. Reports dizziness when getting out of bed to use the bathroom
Correct Answer: C
Rationale: Burning at the IV site suggests possible extravasation or phlebitis, which can lead to tissue damage or infection, requiring immediate intervention. Low blood pressure, falling asleep, and dizziness are less urgent and can be associated with morphine's expected effects.
A woman who has been hospitalized for several days says she is having trouble getting to sleep. What is the best initial nursing intervention?
- A. Offer her a back rub.
- B. Ask her what she is worrying about.
- C. Give the ordered PRN sedative.
- D. Notify the physician.
Correct Answer: A
Rationale: A back rub promotes relaxation non-pharmacologically, addressing insomnia safely. Asking about worries, giving sedatives, or notifying the physician are less immediate.