Nokea
The nurse is preparing to administer prescribed medications to a client via a nasogastric tube connected to low-intermittent suction. The nurse should take which appropriate action? Select all that apply.
- A. Position the client in Trendelenburg position.
- B. Verify correct placement of the tube before medication administration.
- C. Turn off the suction during medication administration.
- D. Resume low-intermittent wall suction immediately after medication administration.
- E. Irrigate the nasogastric tube (NGT) with sterile water.
Correct Answer: B,C
Rationale: Verifying tube placement and turning off suction ensure safe medication administration; Trendelenburg is inappropriate, and sterile water is not required.
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The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee-length elastic stockings (support hose). The teaching plan should include which of the following? Check all that apply.
- A. Apply the elastic stockings in the morning
- B. Remove the stockings if swelling occurs
- C. Apply the stockings while in bed
- D. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff
- E. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings
Correct Answer: A,C
Rationale: Rationales: A) Applying elastic stockings in the morning before edema worsens helps promote venous return. C) Applying them while in bed (before standing) minimizes swelling and eases application. B) Removing stockings for swelling requires medical evaluation, not automatic removal. D) Rolling down to form a cuff creates pressure points, impairing circulation. E) Stockings should be removed daily for skin inspection and hygiene, not kept on for 48 hours.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
- A. Deficient diversional activity related to inability to participate secondary to vertigo.
- B. Risk for injury related to vertigo.
- C. Powerlessness related to inability to influence effects of disease process.
- D. Social isolation related to hearing loss.
Correct Answer: B
Rationale: Risk for injury related to vertigo is the priority due to the high risk of falls and accidents during vertigo attacks, which is a significant concern pre-surgery.
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?
- A. Auscultate the pulses with a stethoscope
- B. Call the physician
- C. Use a Doppler ultrasound device
- D. Inspect the lower left extremity
Correct Answer: C
Rationale: If pedal pulses are not palpable, the next step is to use a Doppler ultrasound device to detect blood flow, as pulses may be weak due to PVD or other causes. Auscultation is not used for peripheral pulses, calling the physician is premature, and inspection is less specific than Doppler assessment.
A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on:
- A. The amount of ulceration of the lesion.
- B. The age of the client.
- C. The location of the lesion on the body.
- D. The thickness of the lesion.
Correct Answer: D
Rationale: Melanoma prognosis primarily depends on lesion thickness (Breslow depth), as thicker lesions indicate deeper invasion and worse outcomes.