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The nurse is caring for a client scheduled to receive enteral feedings via a nasogastric tube (NGT). The nurse plans on initially verifying placement of the NGT by
- A. Obtaining an abdominal x-ray (radiograph).
- B. Aspirating the gastric contents to assess the pH.
- C. Irrigating the tube with 15-20 mL of water to see if it flushes unobstructed.
- D. Inserting 20-30 mL of air into the NGT while auscultating the epigastrium.
Correct Answer: B
Rationale: Aspirating gastric contents to check pH (typically ≤5.5 for gastric placement) is the initial, non-invasive method to verify NGT placement. X-ray is definitive but not initial, irrigation checks patency not placement, and air auscultation is less reliable.
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The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?
- A. You will need to lay flat immediately after this procedure.
- B. A heating pad will be applied to the affected area for pain relief.
- C. Before you eat, your gag reflex will need to return.
- D. You can resume your regular activities and diet right after the procedure.
Correct Answer: A
Rationale: Lying flat post-kidney biopsy prevents bleeding complications. Heating pads are not standard, gag reflex is irrelevant, and immediate activity resumption is unsafe.
The nurse is admitting a client who has cryptococcosis pneumonia. When caring for this client, which of the following actions should the nurse take?
- A. Ensure a hand sanitizing station is near the client's room.
- B. Wear a surgical mask when working within three feet of the client.
- C. Provide disposable dishware for client meals.
- D. Place the client in a private room with monitored negative airflow.
Correct Answer: A
Rationale: Cryptococcosis pneumonia requires standard precautions, including hand hygiene. Masks, disposable dishware, and negative airflow are not needed.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.