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What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?
- A. Flush the feeding tube with water before and after feedings.
- B. Elevate the head of the bed to 30-45 degrees during feedings.
- C. Administer the feeding slowly.
- D. Check the client's weight daily.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.
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A healthcare professional is preparing to insert an IV catheter for an older adult client. Which of the following actions should the professional take?
- A. Shave the hair at the insertion site.
- B. Insert the catheter at a 45-degree angle.
- C. Place the client's arm in a dependent position.
- D. Use a tourniquet to dilate the veins.
Correct Answer: C
Rationale: Placing the client's arm in a dependent position is the correct action when preparing to insert an IV catheter in an older adult client. This position helps dilate the veins naturally by using gravity, making it easier to locate and access suitable veins for the IV catheter insertion. By positioning the arm in a dependent position, the healthcare professional can take advantage of gravity to increase venous distention, aiding in successful IV catheter insertion.
When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?
- A. Wear sterile gloves to remove the old dressing.
- B. Cleanse the wound with an antiseptic solution.
- C. Use clean gloves to apply the new dressing.
- D. Open sterile supplies before donning sterile gloves.
Correct Answer: D
Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.
A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?
- A. Swelling of the affected limb.
- B. Diminished peripheral pulses.
- C. Coolness of the affected limb.
- D. Redness and warmth of the affected limb.
Correct Answer: D
Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.
A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of dairy products.
- B. I will eat more fresh fruits and vegetables.
- C. I will limit my intake of whole grains.
- D. I will consume more red meat.
Correct Answer: B
Rationale: The correct answer is B because increasing the intake of fresh fruits and vegetables can help manage blood pressure. These foods are rich in nutrients like potassium, fiber, and antioxidants, which are beneficial for individuals with hypertension. Dairy products are usually high in saturated fats, which can be detrimental to blood pressure control. Whole grains are generally recommended for their health benefits, including maintaining a healthy weight and heart health. Red meat is often high in saturated fats and can contribute to high blood pressure and other cardiovascular risks.
What is a true statement about caring for a client with a nasogastric (NG) tube?
- A. The NG tube should be flushed with 30 mL of water every 4 hours.
- B. The client should be positioned in a supine position.
- C. The NG tube should be advanced 5 cm if resistance is met.
- D. The client's nasal mucosa should be inspected daily.
Correct Answer: A
Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.