Nokea
The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?
- A. Determining tube placement
- B. Auscultating the bowel sounds
- C. Measuring the intake and output
- D. Establishing the client's baseline weight
Correct Answer: A
Rationale: The nurse avoids injecting any substance into a client's NGT before verifying tube placement because NGTs can migrate out of the stomach. If the NGT is not in the correct location, subsequent injections or feedings through the tube can lead to serious complications such as aspiration. None of the remaining options are priorities before administering an enteral feeding.
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A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
- A. Assist the client in identifying supportive strategies.
- B. Initiate the possibility of placing the baby up for adoption.
- C. Stress the need for Alcoholics Anonymous (AA) meetings.
- D. Encourage the client to continue counseling after the birth.
- E. Encourage the client to participate in her rehabilitation care.
- F. Minimize communication with codependent family members.
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?
- A. Bed rest
- B. Intravenous fluids
- C. Supplemental oxygen
- D. Meperidine hydrochloride
Correct Answer: D
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone. These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. The remaining options are appropriate prescriptions for treating vaso-occlusive pain crisis.
Which action should the nurse implement as part of care for a client after a bone biopsy?
- A. Monitoring the vital signs once per day.
- B. Keeping the area in a dependent position.
- C. Administering intramuscular opioid analgesics.
- D. Monitoring the site for swelling, bleeding, or hematoma formation.
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.
During the assessment, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?
- A. Document the child's physical findings.
- B. Report the case because abuse is suspected.
- C. Refer the family to appropriate support groups.
- D. Assist the family with identifying resources and support systems.
Correct Answer: B
Rationale: The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting the assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. Although the remaining options are appropriate, reporting the findings has priority.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.