Nokea
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
- A. Irrigate the tube with 30 mL of sterile saline every 4 hours.
- B. Keep the head of the bed elevated at 45 degrees.
- C. Check for tube placement every shift.
- D. Clamp the tube when ambulating the client.
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
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A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
A client with a history of gastroesophageal reflux disease (GERD) is prescribed omeprazole (Prilosec). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if heartburn resolves.
Correct Answer: A
Rationale: Omeprazole is most effective when taken before meals to reduce acid production.
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
- A. Tell the client to wait another day to see if other symptoms of the flu appear.
- B. Advise the client to take over-the-counter medication for the flu.
- C. Discuss the importance of maintaining an adequate fluid intake.
- D. Report the client's symptoms to the physician after taking the client's temperature.
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.
The nurse instructs the client in mixing and administering regular and NPH insulin. Which of the following statements indicates that the client needs additional instruction?
- A. I draw up the regular insulin first
- B. I shake the bottle of NPH insulin before drawing it up
- C. I store the insulin in a cool place
- D. I insert the needle at a 90-degree angle
Correct Answer: B
Rationale: Shaking NPH insulin can damage it; it should be gently rolled. Drawing up regular insulin first, cool storage, and a 90-degree injection angle are correct practices.