Nokea
The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse recognizes that the gastric pH confirming proper placement in the stomach is
- A. 3.4
- B. 7
- C. 5.9
- D. 8
Correct Answer: A
Rationale: A gastric pH of ≤5.5 (e.g., 3.4) confirms NGT placement in the stomach. Higher pH values (7 or 8) suggest intestinal or respiratory placement.
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The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation by the charge nurse requires follow-up? A client with
- A. An indwelling urinary catheter bag secured to the bed frame.
- B. Delirium tremens having a peripheral vascular access device (VAD) inserted.
- C. Right-sided weakness with their cane on the left side of the bed.
- D. A belt restraint was applied and secured over the chest.
Correct Answer: C,D
Rationale: A cane on the left side for right-sided weakness is inaccessible, and a belt restraint over the chest is unsafe, risking respiratory compromise. Catheter bag placement and VAD in delirium tremens are appropriate.
The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions?
- A. Droplet precautions
- B. Airborne and contact precautions
- C. Contact and droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Varicella zoster requires airborne and contact precautions due to its transmission via respiratory droplets and direct contact. Other options are insufficient.