Nokea
The nurse is caring for a client with a nasogastric tube. Which action confirms correct placement?
- A. Check pH of aspirate.
- B. Observe for bubbling in water.
- C. Inject air and auscultate.
- D. Visualize tube in the throat.
Correct Answer: A
Rationale: Checking the pH of aspirate (pH ‰¤ 5.5) confirms the tube is in the stomach, ensuring safe placement.
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After going through the necessary procedures for collecting physical evidence after a rape, a client is crying and talking about what happened to her. The nurse should:
- A. Advise the client to try to forget about what happened
- B. Recommend that the client be thankful for the fact that she's alive
- C. Question the client about what she could have done to deter the attack
- D. Listen to the client's descriptions about what occurred
Correct Answer: D
Rationale: Listening to the client's descriptions provides emotional support and validates her experience, which is therapeutic post-trauma. Other responses may minimize or blame the client.
Methylphenidate is prescribed for a child with a diagnosis of attention deficit hyperactivity disorder (ADHD). At which time of day should the nurse instruct the mother to administer the medication?
- A. Before dinner and at bedtime
- B. At the noontime and evening meals
- C. In the morning after breakfast and at bedtime
- D. Before breakfast and before the noontime meal
Correct Answer: D
Rationale: Methylphenidate is a central nervous stimulant and should be taken before breakfast and before the noontime meal. It should not be taken in the afternoon or evening because the stimulating effect causes insomnia. The remaining options are incorrect.
Your client has presented in the emergency department with a sudden onset of shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, neck, and back. Which of the following would you most likely suspect?
- A. Hypovolemic shock
- B. Septic shock
- C. A dissected thoracic aortic aneurysm
Correct Answer: C
Rationale: Sudden onset of these symptoms, especially chest and back pain, suggests a dissected thoracic aortic aneurysm, a life-threatening condition requiring urgent intervention.
The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication?
- A. Pupil response
- B. Prothrombin time
- C. Skin temperature
- D. Intake and output
Correct Answer: D
Rationale: Urinary retention is a side effect of benztropine mesylate, an anticholinergic medication. The nurse needs to observe for dysuria, distended abdomen, voiding in small amounts, and overflow incontinence. The remaining options do not relate to this medication.
A client with a diagnosis of multiple sclerosis is prescribed baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Baclofen, a muscle relaxant, commonly causes drowsiness, which the nurse should monitor in clients with multiple sclerosis.