Nokea
The nurse supervises a student nurse giving medications through a nasogastric tube (NGT) to a client receiving continuous enteral feeding. Which actions by the student require follow-up by the nurse? Select all that apply.
- A. Gives each medication separately
- B. Verifies placement of the NGT prior to medication administration
- C. Elevates the head of the bed to 15 degrees
- D. Adds crushed medications directly to a tube feeding
- E. Crushes each tablet into a fine powder
Correct Answer: C,D
Rationale: Elevating the head of the bed to only 15 degrees (C) is insufficient to prevent aspiration; 30-45 degrees is recommended. Adding crushed medications to the tube feeding (D) can clog the tube or alter medication efficacy. Other actions (A, B, E) are correct.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) cares for a 21-year-old male client
Item 1 of 1
Nurses' Notes
1650: Client reports severe abdominal pain that radiates to his left shoulder. The client was tossing around the football with friends, and after being tackled, he began experiencing intense pain that worsened. He denies any medical history but is currently being treated for infectious mononucleosis and 'needed to get some fresh air,' so he started playing football with friends. During the assessment, the client was alert and fully oriented. He reports his abdominal pain is in the left upper quadrant, which radiates to his shoulder, as an 8/10 on the Numerical Rating Scale. Slight bruising was noted on the client's abdomen. A blotchy rash was observed on his back. His abdomen was slightly distended, taut, and tender to touch. Lung sounds are clear bilaterally. Peripheral pulses 2+. Skin is hot to the touch. Cervical lymphadenopathy is present. Vital signs: T 100.4°F (38°C), P 110, RR 21, BP 115/76.
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. Reports of abdominal pain
- B. Temperature
- C. Pulse
- D. Rash
- E. Cervical lymphadenopathy
- F. Abdominal assessment findings
Correct Answer: A,C,F
Rationale: Severe abdominal pain (A), elevated pulse (C), and abnormal abdominal findings (F) such as distention and tenderness suggest a serious condition like a ruptured spleen, especially given the history of trauma and infectious mononucleosis. These require urgent evaluation.
Which of the following most impacts a client's food preferences?
- A. Culture and cultural background
- B. The frequency of grocery shopping
- C. The availability of foods locally
- D. The costs associated with food
Correct Answer: A
Rationale: Culture and cultural background (A) most significantly influence food preferences due to traditions, beliefs, and dietary practices.
The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)?
- A. Muscle rigidity of the neck
- B. Hyperactive bowel sounds
- C. Frequent diarrhea
- D. Abdominal distention
Correct Answer: A
Rationale: Muscle rigidity of the neck (dystonia) is a serious extrapyramidal side effect of metoclopramide, requiring immediate PHCP notification. Hyperactive bowel sounds, diarrhea, and distention are less urgent or expected with gastroparesis.
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply.
- A. Hyperglycemia
- B. Infection
- C. Air embolism
- D. Cardiac tamponade
- E. Dehydration
Correct Answer: A,B,C
Rationale: TPN risks include hyperglycemia (A) from high glucose content, infection (B) due to central line use, and air embolism (C) from improper line management. Cardiac tamponade (D) and dehydration (E) are less directly associated.
The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
- A. Iron sucrose
- B. Enoxaparin
- C. Sucralfate
- D. Hydroxyurea
Correct Answer: B
Rationale: Enoxaparin, an anticoagulant, increases bleeding risk, which is concerning in a client with occult blood in the stool. Iron sucrose treats anemia, sucralfate protects the gastric mucosa, and hydroxyurea is not directly related to gastrointestinal bleeding.