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The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The client aspirated tube feeding.
- B. The nurse has placed the suction catheter in the esophagus.
- C. This is a normal finding.
- D. The feeding is infusing into the trachea.
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
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A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
- A. Pain in the middle of the night
- B. A bowel movement every 3-5 days
- C. Melena
- D. Episodes of nausea and vomiting
Correct Answer: C
Rationale: Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time. Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.
Which of the following activities have been associated with an increase in lead exposure?
- A. Working with stained glass
- B. Drinking from disposable water bottles
- C. Restoring collectible toys
- D. Drinking coffee and tea from decorative ceramic mugs
- E. Using non-stick cookware
- F. Residing in a home constructed before 1950
Correct Answer: A, C, D, F
Rationale: Lead exposure risks include stained glass work (A), restoring old toys (C), decorative mugs (D), and pre-1950 homes (F) due to lead-based paint or glazes. Disposable bottles (B) and non-stick cookware (E) are not significant sources.
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.
The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
- A. Measuring the urinary output
- B. Checking the vital signs
- C. Encouraging increased fluid intake
- D. Weighing the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.
Which actions should be utilized prior to performing a tub bath on the 80 year-old client?
- A. Fill the tub one-half full of water at should be 46°C.
- B. Put a rubber mat on the bottom of the tub.
- C. Maintain water flow pressure during the bath.
- D. Check water temperature using a bath thermometer.
- E. Wash and dry the client's back moving from shoulders to buttocks.
- F. Perform back massage upon completion of the bath.
Correct Answer: B, D
Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (A) risks burns, and maintaining water flow pressure (C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.