Nokea
The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then
- A. notify the physician.
- B. hold the tube feeding and recheck residual volume in one hour.
- C. administer the prescribed feeding.
- D. reposition the patient in low-Fowler's position.
Correct Answer: B
Rationale: An 80 mL gastric residual (B) indicates potential delayed gastric emptying, requiring the nurse to hold the feeding and recheck in one hour to prevent aspiration. Notifying the physician (A) is premature, administering feeding (C) risks complications, and low-Fowler’s (D) is inappropriate for feeding.
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The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?
- A. obtain a court order for the surgical procedure in place of an informed consent
- B. search the client's belongings for any identification
- C. transport the client to the operating room for surgery immediately
- D. call the police to report the incident, identify the client, and locate the family
Correct Answer: C
Rationale: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?
- A. Notify public health services
- B. Dim the lights in the assigned room
- C. Obtain blood cultures
- D. Explore the client's feelings regarding the diagnosis
Correct Answer: C
Rationale: Obtaining blood cultures (C) is the priority action for suspected bacterial meningitis to confirm the diagnosis and guide antibiotic therapy. While droplet precautions (not listed) are also critical to prevent spread, cultures are the most urgent among the options. Notifying public health (A) is secondary, dimming lights (B) addresses comfort, and exploring feelings (D) is not a priority in an acute infection.