Nokea
The nurse is caring for a client with a nasogastric tube.
- A. What is the most appropriate action for the nurse to take if the nasogastric tube appears occluded?
- B. Replace the nasogastric tube.
- C. Irrigate the tube with warm saline.
- D. Advance the tube 3-5 cm.
- E. Reposition the client to the left side.
Correct Answer: B
Rationale: Irrigating the nasogastric tube with warm saline is the first step to clear an occlusion, restoring function. Replacing the tube is invasive, advancing it risks misplacement, and repositioning does not address the occlusion directly.
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A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
A patient with hyperparathyroidism.
Which symptom is MOST important for the nurse to report to the next shift?
- A. Abdominal discomfort.
- B. Hematuria.
- C. Muscle weakness.
- D. Diaphoresis.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct-hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting