Nokea
The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
- A. Diarrhea
- B. Frequent burping
- C. Headache
- D. Sucking lip motions
Correct Answer: D
Rationale: Sucking lip motions suggest tardive dyskinesia, a contraindication for metoclopramide due to risk of worsening. Diarrhea , burping , and headache are not contraindications.
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The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do?
- A. Ask the client if she feels full
- B. Aspirate the nasogastric tube and check for acid
- C. Change the tubing
- D. Feel over the end of the tube and do not administer if air is felt
Correct Answer: B
Rationale: Aspirating and checking for acidic pH confirms nasogastric tube placement in the stomach, preventing aspiration. Other actions are irrelevant or unsafe.
The nurse is reinforcing postpartum discharge instructions to a client. Which instruction should the nurse include to promote newborn safety?
- A. Avoid using blankets to position the newborn in the car seat
- B. Place the newborn in the prone position in bed while sleeping
- C. Position the newborn's car seat in the back seat facing forward
- D. Remove pillows and loose blankets from the newborn's crib
Correct Answer: D
Rationale: Removing pillows and blankets from the crib reduces SIDS risk. Blankets in car seats are unsafe, prone sleeping increases SIDS risk, and forward-facing car seats are incorrect for newborns.
The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first?
- A. Call the health care provider
- B. Determine the client's peak expiratory flow
- C. Notify the client's parents
- D. Remind the client about avoiding triggers
Correct Answer: B
Rationale: Measuring peak expiratory flow assesses asthma severity first. Calling the provider , notifying parents , or discussing triggers follows based on the assessment.
The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.