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The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure?
- A. The Levin tube remains unclamped for 30 minutes after the feeding.
- B. Sterile equipment is used to administer the feeding.
- C. The amount of the feeding is varied according to the patient's tolerance.
- D. The tube feeding is given at room temperature.
Correct Answer: D
Rationale: minimizes intestinal cramping
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The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 10 breaths/min
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.
The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he felt something give. The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient
- A. with the head of the bed elevated 30°.
- B. with the foot of the bed tilted and the head of the bed down.
- C. with the head of the bed elevated 15°.
- D. with the head of the bed elevated 90°.
Correct Answer: C
Rationale: low Fowler's, reduces stress on suture line, may be placed supine with hips and knees bent
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?
- A. Check the ventilator settings every shift.
- B. Suction the endotracheal tube as needed.
- C. Monitor the client’s oxygen saturation.
- D. Ensure the endotracheal tube is secure.
Correct Answer: D
Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home