Nokea
The nurse is caring for a client with a spinal cord injury at T10. Which finding indicates that the client is experiencing spinal shock?
- A. Absence of reflexes below the injury
- B. Blood pressure of 180/100 mm Hg
- C. Spasticity of the lower extremities
- D. Sweating above the level of injury
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A healthcare professional is educating a client with osteoporosis about dietary management. Which of the following foods should the professional recommend?
- A. Green beans
- B. Fortified cereal
- C. Red meat
- D. White bread
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following statement is NOT true about ethical decision-making?
- A. Uses a framework
- B. Considers patient values
- C. Always quick and easy
- D. Involves reasoning
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?
- A. Monitor gastric residuals every 4 hours.
- B. Position the client in a semi-Fowler's position.
- C. Check for tube placement by auscultating air after feeding.
- D. Warm the formula to body temperature before feeding.
Correct Answer: A
Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration.
The nurse listened to Mr. Gary to build trust. This is an example of?
- A. Therapeutic communication
- B. Reflective practice
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?
- A. Notify the health care provider as soon as possible.
- B. Contact the respiratory department to suction the client.
- C. Hyperoxygenate and hyperventilate the client with an Ambu bag and resuction.
- D. Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.
Correct Answer: D
Rationale: Restlessness and tachycardia during suctioning suggest hypoxia or distress; discontinuing suctioning and monitoring vital signs (D) is the priority to stabilize the client. Notifying the provider (A) or respiratory (B) delays immediate action. Hyperoxygenating and resuctioning (C) risks worsening hypoxia. D is correct. Rationale: Stopping suctioning halts oxygen depletion, allowing recovery, while monitoring guides further intervention, a standard response per airway management protocols. This prevents complications like arrhythmias or desaturation, prioritizing patient safety over premature escalation or repeated procedures in an unstable state.