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The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up?
- A. Advances the tube during the client's inspiration.
- B. Hands the client a cup of water and straw.
- C. Positions the client's head-of-bed at 90 degrees.
- D. Washes the client's bridge of nose with soap and water.
Correct Answer: A
Rationale: Advancing an NGT during inspiration increases the risk of tracheal placement. Providing water, elevating the bed to 90 degrees, and cleaning the nose are appropriate actions.
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The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
The nurse is performing perineal care for a female client. It would be appropriate for the nurse to
- A. Clean the client from the anal area to the urethral area.
- B. Vigorously dry the area with a clean towel.
- C. Ensure that the client's door is kept closed during the procedure.
- D. Use warm water and a soap containing alcohol.
Correct Answer: C
Rationale: Closing the door ensures privacy during perineal care. Cleaning backward risks infection, vigorous drying irritates, and alcohol-soap is harsh.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The occupational health nurse is conducting an in-service on reducing back injuries. Which of the following statements, if made by a participant, would indicate a correct understanding of the conference?
- A. I should keep my legs straight while lifting.
- B. Heavy objects should be held away from my body.
- C. I shouldn't twist while lifting an object.
- D. I should keep a narrow base of support.
Correct Answer: C
Rationale: Avoiding twisting while lifting reduces back strain. Other options are incorrect ergonomic practices.
The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.