Nokea
The nurse is to administer a nasogastric tube feeding to a client. Which action is essential prior to administering the feeding?
- A. Position the client in supine position.
- B. Aspirate contents from the nasogastric tube and check the pH.
- C. Check the client's vital signs.
- D. Ask the client if she feels full.
Correct Answer: B
Rationale: Aspirating and checking pH confirms nasogastric tube placement in the stomach, preventing aspiration during feeding.
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During the first 72 hours post CVA, the nurse should position the client:
- A. Supine
- B. Semi-Fowler
- C. Left Sim's
- D. Prone
Correct Answer: B
Rationale: Semi-Fowler's position (30-45 degrees) reduces intracranial pressure and promotes venous drainage in the acute phase post-stroke.
The spouse of a client who had an angioplasty following a heart attack says to the nurse, 'What is an angioplasty? It sounds like plastic surgery. My husband had a heart attack.' What information should be included in the nurse's response?
- A. An angioplasty repairs the heart damage caused by the heart attack.
- B. During an angioplasty, the physician creates a bypass around blocked arteries, increasing the blood flow to the heart muscle.
- C. Angioplasty is a diagnostic procedure to see if there are any blocked coronary arteries.
- D. During an angioplasty, the physician uses a balloon-tipped catheter to open up an artery that is blocked by a clot, thus increasing blood flow to the heart muscle.
Correct Answer: D
Rationale: An angioplasty is the insertion of a balloon-tipped catheter into a coronary artery. The balloon is inflated, opening up the artery and increasing blood flow through the coronary artery to the heart muscle. Angioplasty does not repair heart damage. A left heart cardiac catheterization is the diagnostic procedure that precedes angioplasty. Answer 2 describes a coronary artery bypass graft (CABG) procedure.
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Some increase in the serum hemoglobin
- D. A little decrease in the serum potassium
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
- A. A new mother is breastfeeding her two-day-old infant who was born five days early.
- B. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
- C. An elderly woman discharged from the hospital three days ago with pneumonia.
- D. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
The nurse is caring for a client with a history of pancreatitis.
- A. Which dietary instruction is most appropriate for a client with chronic pancreatitis?
- B. High-fat, low-protein diet.
- C. Low-fat, high-protein diet.
- D. High-carbohydrate, low-fat diet.
- E. Low-carbohydrate, high-fat diet.
Correct Answer: B
Rationale: A low-fat, high-protein diet reduces pancreatic stimulation and supports tissue repair in chronic pancreatitis. High-fat diets exacerbate symptoms, and carbohydrate balance is less critical.