Nokea
The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do?
- A. Ask the client if she feels full
- B. Aspirate the nasogastric tube and check for acid
- C. Change the tubing
- D. Feel over the end of the tube and do not administer if air is felt
Correct Answer: B
Rationale: Aspirating and checking for acidic pH confirms nasogastric tube placement in the stomach, preventing aspiration. Other actions are irrelevant or unsafe.
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The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
- A. A visitor talking in the waiting room states that the client has alcoholism
- B. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
- C. The nursing assistant tells a client that the hospital roommate went for a gallbladder test
- D. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
- E. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Correct Answer: A,B,C
Rationale: Visitor disclosure , taking reports home , and sharing roommate info violate confidentiality. Isolation precautions and general discussion do not.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.
The nurse is preparing to administer scheduled vaccines to a 15-month-old client with Kawasaki disease. The client received IV immunoglobulin 2 months ago. Which of the following vaccines should be delayed? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis B
- C. Measles, mumps, and rubella
- D. Pneumococcal conjugate
- E. Varicella
Correct Answer: C,E
Rationale: MMR and varicella are live vaccines, which should be delayed 11 months post-IVIG due to antibody interference. Hib , hepatitis B , and pneumococcal are not affected.
The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Encourage the client to turn the head to the left occasionally while eating
- B. Add milk to the client's mashed potatoes to make the consistency thinner.
- C. Provide a straw for the client to use while drinking a fruit smoothie.
- D. Place food on the stronger side of the client's mouth
- E. Assist the client to sit in an upright position.
Correct Answer: D,E
Rationale: Placing food on the stronger side and upright positioning reduce aspiration risk. Head turning may not help right-sided stroke, thinning food increases aspiration, and straws are unsafe.