Nokea
The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Secure the tube to the client's gown.
- C. Check the placement of the tube by auscultation.
- D. Irrigate the tube with normal saline every shift.
Correct Answer: A
Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.
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The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.
- B. Oh, that behavior will stop in a few days.
- C. Keep in mind that for the age this is a normal response to being in the hospital.
- D. You might want to 'sneak out' of the room once the child falls asleep.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When ambulating a frail, older adult client, the nurse should:
- A. Use the transfer belt if the client is unsteady
- B. Walk beside the client without support
- C. Encourage the client to use a walker
- D. Hold the client's arm for support
Correct Answer: A
Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.
The client is receiving discharge instructions for warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will have my blood tested regularly to monitor my INR levels.
- C. I will take the medication at the same time every day.
- D. I will use a soft toothbrush to prevent bleeding gums.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin need to be consistent with their vitamin K intake to maintain a balance in blood clotting. Avoiding foods high in vitamin K is essential as they can interfere with the medication's effectiveness. Choices B, C, and D are all correct statements regarding warfarin therapy. Regular blood testing to monitor INR levels ensures the medication is working effectively, taking the medication at the same time daily maintains a consistent level in the bloodstream, and using a soft toothbrush helps prevent gum bleeding due to warfarin's anticoagulant effects.
A client is grieving the loss of her partner and expresses thoughts of not seeing the point of living anymore. What action should the nurse take?
- A. Recommend that the client seek spiritual guidance
- B. Request additional support from the client's family
- C. Tell the client that this is a normal response to grief
- D. Ask the client if she plans to harm herself
Correct Answer: D
Rationale: When a client expresses feelings of hopelessness or worthlessness, it is crucial for the nurse to assess for suicidal ideation. Asking the client directly if she plans to harm herself is essential to determine the level of risk and ensure appropriate interventions are implemented. Recommending spiritual guidance (Choice A) may not address the immediate safety concerns related to suicidal ideation. Requesting additional support from the client's family (Choice B) is not as direct in addressing the client's safety. While stating that the client's response is a normal part of grief (Choice C) may provide validation, it does not address the potential risk of harm to the client.
A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 100 mL/hr
- B. 150 mL/hr
- C. 75 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.