Nokea
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
- A. From the tip of the nose to the earlobe
- B. From the tip of the earlobe to the xiphoid process
- C. From the tip of the earlobe to the nose to the xiphoid process
- D. From the tip of the nose to the earlobe to the xiphoid process
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement.
Summary of Incorrect Choices:
A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach.
B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage.
D: Measuring from the tip of the nose to the earlobe to
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A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.
A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo?
- A. Lymphadenectomy
- B. Needle biopsy
- C. Open biopsy
- D. Sentinel node biopsy
Correct Answer: D
Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
- A. Foods
- B. Medications
- C. Insect stings
- D. Autoimmunity E) Environmental pollutants
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?
- A. Identify the triggers that precipitated the seizure.
- B. Implement precautions to ensure the patients safety.
- C. Teach the patients family about the relationship between brain tumors and seizure activity.
- D. Ensure that the patient is housed in a private room.
Correct Answer: B
Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.