Nokea
The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube and a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply.
- A. Administer the scheduled feeding as prescribed.
- B. Discard the aspirated residual in a biohazard container.
- C. Place the client in the high-Fowler position during the feeding.
- D. Flush the nasogastric tube before and after administering the feeding.
- E. Check the pH of the residual and notify the health care provider if the pH is > 5.
Correct Answer: A,C,D
Rationale: A residual of 75 mL is typically acceptable to proceed with feeding. High-Fowler position and flushing are standard. Residual is returned, not discarded, and pH >5 is not concerning.
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A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
- A. pulmonary embolectomy
- B. vena caval interruption
- C. increasing the Coumadin therapy to an INR of 3-4
- D. thrombolytic therapy
Correct Answer: B
Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.
The nurse is talking with a female client about collecting a clean-catch urine specimen. Which of the following information should the nurse include? Select all that apply.
- A. Avoid touching the inside of the specimen container.
- B. Position the specimen container before initiating your stream of urine.
- C. Cleanse your vulva from front to back with single-use antiseptic towelettes.
- D. Spread your labia using your nondominant hand before cleansing your perineum and urinating.
- E. Remove the lid from the specimen container and place it on the counter with the sterile side facing down.
Correct Answer: A,C,D
Rationale: Avoiding contamination, proper cleansing, and spreading the labia are critical for a clean-catch specimen. The lid should be placed sterile side up, and the container should be positioned midstream.
The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?
- A. Mild bruising or redness may occur at the injection site.
- B. Eliminate green, leafy, vitamin K-rich vegetables from your diet.
- C. Black stools are a common, harmless adverse effect of the medication.
- D. Take over-the-counter medications such as ibuprofen to relieve mild discomfort.
Correct Answer: A
Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.