Nokea
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
- A. There is a sudden decrease in output.
- B. The NGT is set to low continuous suction.
- C. The NGT is set to medium intermittent suction.
- D. The patient is positioned in the semi-Fowler's position.
- E. The client dislodges the tube and the nurse replaces it, confirming placement by X-ray before use.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
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A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
- A. Keeping the environment free of clutter
- B. Advising the client to see the dentist regularly
- C. Encouraging the client to take the influenza vaccine
- D. Telling the client to take a daily multivitamin
Correct Answer: A
Rationale: Paget's disease increases fracture risk, so keeping the environment clutter-free reduces fall risks, a key preventive measure.
Which information should be reported to the state Board of Nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past 3 days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Correct Answer: B
Rationale: Incorrect narcotic counts suggest potential diversion or mismanagement of controlled substances, which must be reported to the state Board of Nursing.
The nurse is preparing to administer a dose of regular insulin to a client based on a sliding scale. The client’s blood glucose is 320 mg/dL. The sliding scale orders 6 units of regular insulin for a blood glucose of 301–350 mg/dL. Which of the following actions should the nurse take?
- A. Administer 6 units of regular insulin.
- B. Administer 8 units of regular insulin.
- C. Withhold the insulin and notify the physician.
- D. Recheck the blood glucose in 30 minutes.
Correct Answer: A
Rationale: the sliding scale indicates 6 units for a blood glucose of 320 mg/dL, so the dose is correct
The infant is admitted to the unit with Tetralogy of Fallot. The nurse would anticipate an order for which medication?
- A. Digoxin
- B. Epinephrine
- C. Aminophyline
- D. Atropine
Correct Answer: A
Rationale: Digoxin is commonly used in Tetralogy of Fallot to improve cardiac function and manage heart failure symptoms.