Nokea
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration
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The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
- A. Hold the next feeding.
- B. Teach the mother CPR.
- C. Maintain a normal feeding schedule.
- D. Elevate the head of the bed.
Correct Answer: D
Rationale: infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle
A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST?
- A. Observe the client for eight hours to collect additional data.
- B. Perform a complete physical assessment.
- C. Collect a urine specimen for a drug screen.
- D. Encourage the client to talk about whatever is bothering him.
Correct Answer: B
Rationale: best way to identify possible physical complications of alcohol dependence is through a complete physical assessment