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The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
- A. boot (shoe) covers
- B. face shield
- C. surgical mask
- D. gown
Correct Answer: C
Rationale: Haemophilus influenzae, type b meningitis requires droplet precautions, which include wearing a surgical mask when within 3 feet of the client. Boot covers, face shields, and gowns are not specifically required unless additional risks (e.g., splashing) are present.
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A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.
The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up?
- A. Advances the tube during the client's inspiration.
- B. Hands the client a cup of water and straw.
- C. Positions the client's head-of-bed at 90 degrees.
- D. Washes the client's bridge of nose with soap and water.
Correct Answer: A
Rationale: Advancing an NGT during inspiration increases the risk of tracheal placement. Providing water, elevating the bed to 90 degrees, and cleaning the nose are appropriate actions.
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.
The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The nurse is developing a care plan for a child scheduled to be admitted to the oncology unit to receive treatment for leukemia. To facilitate effective transition to the hospitalized environment, the nurse should recommend that the parents
- A. Purchase new toys for the child.
- B. Allow flexibility in the daily routine, so it changes often.
- C. Bring in the child's favorite toys from home.
- D. Limit parental visitation to specific times.
Correct Answer: C
Rationale: Familiar toys provide comfort, easing the hospital transition. New toys lack familiarity, flexible routines disrupt stability, and limited visitation increases anxiety.