Nokea
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
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A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?
- A. Notify the physician of readings less than 3 cm or more than 8 cm of water
- B. Use the clean technique to change the dressing at the insertion site
- C. Elevate the head of the bed to 90° to obtain CVP readings
- D. The 0 mark on the manometer should align with the client's right clavicle for the readings
Correct Answer: A
Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?
- A. Post-coital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Post-coital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor friability. The other symptoms are less specific or related to advanced disease.
A student nurse is assigned to care for a client in a protective environment room. The nurse knows to intervene upon observing which of the following deliveries by the nursing student?
- A. indwelling catheterization kit
- B. flower bouquet
- C. tray of food containing disposable plate and utensils
- D. oral medication
Correct Answer: B
Rationale: Flowers can introduce allergens or pathogens, which are contraindicated in a protective environment. Other items are safe if sterile or disposable.
Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:
- A. Prevention of nausea and vomiting
- B. Treatment of micro-metastasis
- C. Eradication of bone pain
- D. Prevention of therapy-induced anemia
Correct Answer: B
Rationale: Intra-arterial chemotherapy can treat micro-metastases by delivering high drug concentrations to the tumor and surrounding areas.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin
- B. Ampicillin
- C. Propranolol
- D. Verapamil
Correct Answer: B
Rationale: Ampicillin, an antibiotic, is not indicated for chest pain, which is typically cardiac-related and treated with nitroglycerin, propranolol, or verapamil.