Nokea
The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
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The nurse creates a postoperative plan of care for a client scheduled for a hypophysectomy. Which interventions should be included in the plan of care? Select all that apply.
- A. Obtain daily weights.
- B. Monitor intake and output.
- C. Elevate the head of the bed.
- D. Use a soft toothbrush for mouth care.
- E. Encourage coughing and deep breathing.
Correct Answer: A,B,C
Rationale: A hypophysectomy is done to remove a pituitary tumor. Because temporary diabetes insipidus or syndrome of inappropriate antidiuretic hormone can develop after this surgery, obtaining daily weights and monitoring intake and output are important interventions. The head of the bed is elevated to assist in preventing increased intracranial pressure. Tooth-brushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy because of the risk of increasing intracranial pressure. These activities interfere with the healing of the incision and can disrupt the graft.
The client states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
- A. Orthopnea
- B. Dyspnea at rest
- C. Dyspnea on exertion
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a 'three-point' position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
- A. The infant exhibits dimpling of the cheeks.
- B. The infant makes smacking or clicking sounds.
- C. The mother's breast gets softer during a feeding.
- D. Milk drips from the mother's breast occasionally.
- E. The infant falls asleep after feeding less than 5 minutes.
- F. The infant can be heard swallowing frequently during a feeding.
Correct Answer: A,B,E
Rationale: Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.
A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?
- A. Cover the client with warm blankets.
- B. Minimize visual and auditory stimuli present.
- C. Elevate the client's head to at least 45 degrees.
- D. Administer oxygen at 4 L per minute by nasal cannula.
Correct Answer: C
Rationale: Excess fluid volume can lead to symptoms such as shortness of breath and cerebral edema, which can be alleviated by elevating the head of the bed to at least 45 degrees to promote venous drainage and reduce intracranial pressure. This is a safe and effective nursing intervention to increase comfort until specific medical therapy is prescribed.