Nokea
The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?
- A. Elevate the head of the bed to 15 degrees during feedings
- B. Aspirate gastric contents before administering medications
- C. Clamp the tube between feedings
- D. Flush the tube with water before and after feedings
Correct Answer: D
Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.
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A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?
- A. Baked apples with raisins.
- B. Yogurt with fresh berries.
- C. Avocados and cheese.
- D. Fresh fruit salad.
Correct Answer: B
Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.
A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still takes hours to fall asleep at night. Which action should the nurse implement?
- A. Advise the client to reduce exercise intensity
- B. Ask the client for a description of the exercise schedule that is being followed
- C. Encourage the client to try relaxation techniques before bed
- D. Suggest avoiding water-based exercise before bed
Correct Answer: B
Rationale: Asking the client for a description of the exercise schedule being followed is the most appropriate action for the nurse to take in this scenario. Understanding the timing and intensity of the client's exercise routine can help identify if the activity is contributing to sleep disturbances. Exercise too close to bedtime can cause difficulty falling asleep. Choices A, C, and D do not directly address the need to assess the exercise schedule and may not provide the necessary information to identify the potential cause of the client's sleep issue.
Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
- A. White blood cell count.
- B. Prothrombin time (PT) and International Normalized Ratio (INR).
- C. Hemoglobin and hematocrit.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.
A client with hypertension is prescribed hydrochlorothiazide. What teaching should the nurse provide?
- A. Take the medication in the morning to avoid frequent urination at night.
- B. Increase fluid intake to prevent dehydration.
- C. Avoid potassium-rich foods, such as bananas and oranges.
- D. Monitor the client's potassium levels weekly.
Correct Answer: B
Rationale: The correct teaching for a client prescribed hydrochlorothiazide is to increase fluid intake to prevent dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalances, so adequate fluid intake is crucial. Choice A is incorrect because hydrochlorothiazide is typically taken in the morning to avoid nighttime urination. Choice C is incorrect as potassium-rich foods should not be avoided but monitored, as hydrochlorothiazide can cause potassium loss. Choice D is incorrect as potassium levels should be monitored regularly, but not necessarily weekly, unless indicated by the healthcare provider.
A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give sugar water only.
- B. Offer the infant oral rehydration every 2 hours.
- C. Provide Pedialyte feedings via nasogastric tube.
- D. Maintain intravenous fluid therapy.
Correct Answer: D
Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.