Nokea
The provider order reads 'Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?
- A. Hold the tube feeding and notify the provider
- B. Administer the tube feeding as scheduled
- C. Irrigate the tube with diet cola soda
- D. Apply intermittent suction to the feeding tube
Correct Answer: A
Rationale: Hold the tube feeding and notify the provider. A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.
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A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?
- A. bleeding time
- B. platelet count
- C. activated PTT
- D. clotting time
Correct Answer: C
Rationale: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?
- A. Wipe up the stool with toilet paper and then clean the area with soap and water
- B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution
- C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket
- D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool
Correct Answer: B
Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.
A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
- A. I knew this would happen. I've been eating too much red meat lately.'
- B. I really enjoyed my fishing trip yesterday. I caught two fish.'
- C. I have really been working hard practicing basketball.'
- D. I went to get a cold checked out last week, and I have gotten worse.'
Correct Answer: D
Rationale: I went to get a cold checked out last week, and I have gotten worse.' Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.