Nokea
The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. The nurse should place the client in which position to administer the feeding?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Lateral recumbent
Correct Answer: B
Rationale: Clients are at high risk for aspiration during an NG tube feeding because the tube bypasses a protective mechanism, the gag reflex. The head of the bed is elevated 35 to 40 degrees (Semi-Fowler's) to prevent this complication by facilitating gastric emptying. The remaining options increase the risk of aspiration by blunting the effect of gravity on gastric emptying.
You may also like to solve these questions
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident?
- A. I will never be able to operate a microwave oven again.
- B. I should expect occasional feelings of dizziness and fatigue.
- C. I will take my pulse in the wrist or neck daily and record it in a log.
- D. Moving my arms and shoulders vigorously helps check pacemaker functioning.
Correct Answer: C
Rationale: Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the primary health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the primary health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.
A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure?
- A. Mole skin-lined heel protectors
- B. Regular use of posterior splints
- C. Application of pneumatic boots
- D. Avoiding dorsal flexion of the foot
Correct Answer: B
Rationale: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.
What should the pregnant client be taught to immediately eliminate in the first trimester to promote normal fetal organ development?
- A. Smoking
- B. Caffeine
- C. Alcohol
- D. Fatty foods
Correct Answer: C
Rationale: The first trimester, 'organogenesis,' is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this critical period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development. Although options 1, 2, and 3 may be concerns, they are not specifically associated with the first trimester of pregnancy.
The nurse monitors a client prescribed a thiazide diuretic for which clinical manifestations of hypokalemia? Select all that apply.
- A. Muscle twitches
- B. Deep tendon hyporeflexia
- C. Prominent U wave on ECG
- D. General skeletal muscle weakness
- E. Hypoactive to absent bowel sounds
- F. Tall T waves on electrocardiogram (ECG)
Correct Answer: B,C,D,E
Rationale: Hypokalemia is a serum potassium level less than 3.5 mEq/L. Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.