Nokea
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.
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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.
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.
The nurse is reinforcing teaching about circumcision care with the parent of a newly circumcised newborn. Which statement by the parent would require follow-up?
- A. I should change my baby's diaper at least every 4 hours.
- B. I should notify the health care provider if there is odorous discharge from the site.
- C. I will apply light pressure with gauze if there is bleeding at the site.
- D. I will clean the site with alcohol-based wipes or soap and water.
Correct Answer: D
Rationale: Alcohol-based wipes are too harsh for a circumcision site; gentle soap and water are recommended, requiring follow-up. Other statements are correct.
The nurse is teaching an elderly client how to use MDIs (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
- A. Nebulized treatments for home care
- B. Adding a spacer device to the MDI canister
- C. Asking a family member to assist the client with the MDI
- D. Request a visiting nurse to follow the client at home
Correct Answer: B
Rationale: If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.
Which group of food selections would be appropriate for a client on a full liquid diet 3 days after bariatric surgery?
- A. Apple juice, mashed potatoes, and chocolate pudding
- B. Chicken broth, low-fat cheese omelet, and strawberry ice cream
- C. Creamy wheat cereal, blended cream of chicken soup, and a protein shake
- D. Low-fat vanilla yogurt, smooth peanut butter, and vegetable juice
Correct Answer: C
Rationale: Creamy wheat cereal, blended soup, and protein shakes are full liquids suitable post-bariatric surgery. The other options include solid foods.