Nokea
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
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The nurse is changing a dressing. Which event indicates a break in sterile technique?
- A. The nurse opens the sterile dressing set by opening the first flap away from herself.
- B. The nurse turns around when answering a question asked by the client in the other bed.
- C. The nurse opens the dressing set on the overbed table.
- D. The nurse pours sterile saline into the container in the dressing set.
Correct Answer: B
Rationale: Turning around risks contaminating the sterile field by passing non-sterile areas over it. Opening flaps away, using the table, or pouring saline maintain sterility.
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
- A. History of obesity
- B. Prescribed use of a monoamine oxidase (MAO) inhibitor
- C. Diagnosis of vascular disease
- D. Takes antacids frequently
Correct Answer: B
Rationale: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.