The nurse is caring for a client with a jejunostomy tube rec...

The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would reduce this client's aspiration risk?

A. Flush tubing with 10 mL water after feeding is completed
B. Assess the client's gag reflex prior to feeding
C. Assess blood glucose every 6 hours
D. Position the client in semi-Fowler's during and after the feeding

Correct Answer: D

Rationale: Positioning the client in semi-Fowler's (30-45 degrees) during and after feeding reduces aspiration risk by using gravity to prevent gastric contents from refluxing.

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The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse

A. Multiple glass tables in the living room
B. Multiple feather pillows present on the bed
C. Padded covers on the edges of countertops
D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
E. Kitchen knives were readily accessible
F. Client reports using the microwave instead of the stove
G. Locks on the bathroom door

Correct Answer: A,D,E,G

Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.

The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this age group, should be aware that:

A. The child will do something for another person if that person does something for the child.
B. The child now follows social standards for the good of all.
C. The child wants to follow the rules because of a need to be seen as 'good.'
D. The child finds satisfaction in following rules.

Correct Answer: C

Rationale: 10-year-olds are in Kohlberg’s conventional stage, seeking approval by following rules to be seen as 'good.' Reciprocity, societal good, or intrinsic satisfaction are less applicable.

The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply.

A. Providing a meal tray
B. Changing bed linens
C. Replacing a suction canister
D. Obtaining vital signs
E. Providing range of motion exercises

Correct Answer: C,D

Rationale: Two client identifiers are required for procedures that involve direct client intervention with potential for error, such as replacing a suction canister (invasive equipment) and obtaining vital signs (recorded in medical records). Providing a meal tray, changing bed linens, and range of motion exercises do not typically require two identifiers.

The nurse is teaching a client who recently had a femoral vein central line catheter placed. Which of the following information should the nurse include?

A. You will need to avoid drinking more than 500 mL per day.
B. You will clean the site daily with soap and water.
C. You should not sit up more than 45 degrees.
D. You can remove the dressing if it becomes itchy.

Correct Answer: B

Rationale: Daily cleaning with soap and water maintains hygiene at the femoral central line site. Fluid restriction, angle limitation, and patient removal of dressings are incorrect and unsafe.

The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?

A. Blood pressure
B. End-tidal carbon dioxide [ETCO2] level
C. Respiratory rate
D. Blood glucose
E. Oxygen saturation

Correct Answer: A,B,C,E

Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.