Nokea
The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.
- A. Fold tube in half and mark at the halfway point
- B. Extend tape measure from naris to stomach
- C. Measure from tip of nose to earlobe to xiphoid process
- D. Place a small piece of tape at the point of measurement
- E. Use rubber clamp after measuring to mark the point of measurement
Correct Answer: C,D
Rationale: To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.
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Which client condition is concerning and requires further nursing observation and intervention? Select all that apply.
- A. Client with asthma exacerbation and blood pressure is 150/90 mm Hg
- B. Client with spinal cord injury and blood pressure is 50/60 mm Hg
- C. Client with coronary artery disease on metoprolol, pulse is 62/min
- D. Elderly client with black stool; pulse is 112/min
- E. Neonate crying inconsolably at feeding time; pulse is 160/min
Correct Answer: B,D,E
Rationale: Concerning conditions include: spinal cord injury with hypotension suggesting neurogenic shock; black stool and tachycardia indicating possible GI bleeding; and inconsolable neonate with tachycardia suggesting distress. Asthma with hypertension and stable pulse on metoprolol are less urgent.
The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?
- A. Asking the physician for a sleeping medication
- B. Offering the client a back rub
- C. Asking the client if she is concerned about something
- D. Repositioning the client
Correct Answer: A
Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.
The nurse is reviewing new medication prescriptions for a client with asthma and nasal polyps. The nurse should clarify the prescription for
- A. ibuprofen
- B. vitamin D
- C. albuterol
- D. montelukast
Correct Answer: A
Rationale: Ibuprofen should be clarified in asthma with nasal polyps due to risk of aspirin-exacerbated respiratory disease. Vitamin D , albuterol , and montelukast are safe.
The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?
- A. Lower extremity pulses, paresthesias, and pain
- B. The presence of bowel sounds
- C. Radial pulse, sensation, and movement of the arms
- D. Palpation of the bladder
Correct Answer: A
Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.