Nokea
The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?
- A. To prevent dehydration
- B. To divert the client's attention
- C. To close the epiglottis
- D. To lubricate the tube
Correct Answer: C
Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.
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The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to
- A. determine oxygen saturation
- B. measure forced expiratory volume
- C. monitor atmosphere for severe of allergens
- D. provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.
A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
- A. increased temperature and lethargy
- B. restlessness and increased mucus production
- C. increased sleeping and listlessness
- D. diarrhea and poor skin turgor
Correct Answer: B
Rationale: This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
- A. Report signs of redness overlying a joint
- B. Monitor the client's response to ambulatory activity
- C. Encouragement for the independence in self-care
- D. Assist the client to transfer from a bed to a chair
Correct Answer: B
Rationale: Monitor the client's response to interventions requires assessment, a task to be performed by an RN.
An adult client in an acute care facility says to the nurse, 'I hope this hospital doesn't have student doctors and nurses. I do not want a student taking care of me.' The nurse's response should be based on which of the following understandings?
- A. When a client signs permission for treatment in a hospital, this includes treatment by medical and nursing students.
- B. The client has the right to know if the hospital is affiliated with a medical school and to refuse care by students.
- C. The client may sign a special form that says he refuses to be cared for by medical or nursing students.
- D. The client should be informed if any caregivers are students, but the client does not have the right to refuse to be cared for by students.
Correct Answer: B
Rationale: Clients have the right to know about student involvement and refuse student care, respecting autonomy. Consent doesn't inherently include students, and special forms or mandatory acceptance are incorrect.