Nokea
The nurse is observing a student nurse administer a client's medications via a nasogastric (NG) tube. The nurse understands that the student nurse needs further teach if the student nurse performs which action?
- A. aspirates and checks the residual
- B. places client in the semi-Fowler's position
- C. verifies that the medications may be given via NG tube
- D. stops the tube feeding before medication administration
- E. flushes tubing with 15-30 cc of water after administering meds
- F. None
- G. all the above
Correct Answer: F
Rationale: All listed actions are correct for NG medication administration. No intervention is needed.
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The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
- A. Hip
- B. Ankle
- C. Earlobe
- D. Chin
Correct Answer: C
Rationale: The earlobe is a suitable site for pulse oximetry in peripheral vascular disease, as it is less affected by impaired peripheral circulation.
A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
- A. small-bowel lesion
- B. basilar skull fracture
- C. acute coronary syndrome
- D. use of diabetic insulin pump
Correct Answer: B
Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain a culture of:
- A. Blood
- B. Nasopharyngeal secretions
- C. Stool
- D. Genital secretions
Correct Answer: D
Rationale: Gonorrhea is diagnosed by culturing genital secretions.
The physician has prescribed Gantrisin (sulfasoxazole) 1 g in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
- A. With meals or a snack
- B. 30 minutes before meals
- C. 30 minutes after meals
- D. At bedtime
Correct Answer: A
Rationale: Gantrisin should be taken with food to reduce gastrointestinal upset, and adequate fluid intake is needed to prevent crystalluria.
A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is
- A. I am so sorry. I am divorced too, but it worked out for the best.'
- B. About half of marriages end in divorce these days.'
- C. You have to let him go and move on with your life.'
- D. Tell me what happened.'
Correct Answer: D
Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.