Nokea
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
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The nurse administers theophylline (TheoDur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
- A. Suppression of the client's respiratory infection.
- B. Decrease in bronchial secretions.
- C. Relaxation of bronchial smooth muscle.
- D. Thinning of tenacious, purulent sputum.
Correct Answer: C
Rationale: Theophylline relaxes bronchial smooth muscle, relieving bronchospasm in COPD. It does not suppress infection, reduce secretions, or thin sputum.
Which of the following is an appropriate expected outcome for a client recovering from a total laryngectomy? The client will:
- A. Regain the ability to taste and smell food.
- B. Demonstrate appropriate care of the gastrostomy tube.
- C. Communicate feelings about body image changes.
- D. Demonstrate sterile suctioning technique for stoma care.
Correct Answer: C
Rationale: Communicating feelings about body image changes is an appropriate psychosocial outcome post-laryngectomy, addressing adaptation to altered appearance. Taste and smell may be impaired long-term. Gastrostomy tubes are not always required. Sterile suctioning is a nursing task, not a client outcome.
Which of the following lifestyle modifications should the nurse encourage the client with a hiatal hernia to include in activities of daily living?
- A. Daily aerobic exercise.
- B. Eliminating smoking and alcohol use.
- C. Balancing activity and rest.
- D. Avoiding high-stress situations.
Correct Answer: B
Rationale: Eliminating smoking and alcohol is critical for managing hiatal hernia, as both can relax the lower esophageal sphincter and worsen reflux.
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client:
- A. You can sit up whenever you want.'
- B. You must lie flat on your back most of the time.'
- C. You can turn your body.'
- D. You must lie on your stomach.'
Correct Answer: B
Rationale: Buck's traction requires lying flat to maintain traction alignment, limiting movement.
The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what clients with this disorder typically see
- A. degeneration-1.png
- B. degeneration-2.png
- C. degeneration-3.png
- D. degeneration-4.png
Correct Answer: C
Rationale: In macular degeneration the center vision is blackened out and only the outer visual fields are clear.