Nokea
The nurse is preparing to administer a medication to a client via a nasogastric tube. Which of the following actions should the nurse perform FIRST?
- A. Check the placement of the nasogastric tube.
- B. Crush the medication and mix with water.
- C. Flush the tube with 30 mL of water.
- D. Position the client in a supine position.
Correct Answer: A
Rationale: Verifying nasogastric tube placement prevents aspiration, a priority before medication administration. Options B, C, and D follow placement confirmation.
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Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
The nurse who is the primary caregiver for an adult client receives a telephone report from the Microbiology Department that the client's blood culture is positive for gram-negative rods. The client is not on antibiotics. What should the nurse do first?
- A. Document the result in the appropriate area of the chart
- B. Inform the client that the nurse now knows what is causing his illness
- C. Place a call to the physician and document the results of the lab work and the notification of the physician in the nurse's notes
- D. Place the laboratory report on the client's chart as soon as possible
Correct Answer: C
Rationale: Notifying the physician promptly ensures timely antibiotic initiation for a positive blood culture, the priority action.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.