Nokea
The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?
- A. Places the end of the NG tube in a cup of water and watches for bubble formation.
- B. Checks the pH of the contents aspirated from the NG tube.
- C. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
- D. Uses a large barreled syringe to aspirate for stomach contents.
Correct Answer: A
Rationale: not considered acceptable procedure
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The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
The nurse is monitoring a 20-year-old woman in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if
- A. the contractions occur at 3-minute intervals and last more than 60 seconds.
- B. the contractions occur at 2.5-minute intervals and last more than 60 seconds.
- C. the contractions occur at 2-minute intervals and last more than 90 seconds.
- D. the contractions occur at 2-minute intervals and last more than 60 seconds.
Correct Answer: C
Rationale: contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds) allows for longer resting time between contractions
While performing care for a 72-year-old woman, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should
- A. brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
- B. use glycerin swabs to perform mouth care every 4 hours.
- C. rinse the patient's mouth with room-temperature tap water before and after meals.
- D. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.
Correct Answer: C
Rationale: will hydrate the mucous membranes and keep mouth clean