Nokea
What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?
- A. Elevate the head of the bed to 30-45 degrees.
- B. Check residual volumes every 4 hours.
- C. Verify tube placement every shift.
- D. Flush the tube with water every 4 hours.
Correct Answer: A
Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.
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A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:
- A. Cotton balls
- B. Sterile gloves
- C. A suction catheter
- D. Tracheostomy tubes
Correct Answer: A
Rationale: The correct answer is A: Cotton balls. Cotton balls are not suitable for tracheostomy care due to the risk of lint and contamination. When performing tracheostomy care, sterile supplies such as sterile gloves, a suction catheter, and tracheostomy tubes are essential. Sterile gloves are needed to maintain asepsis, a suction catheter is necessary for airway clearance, and tracheostomy tubes are crucial for maintaining a patent airway. Cotton balls should be avoided to prevent introducing lint or fibers into the tracheostomy site, which can lead to infection or airway obstruction.
A client has extracellular fluid volume deficit. Which of the following findings should the nurse expect?
- A. Postural hypotension
- B. Distended neck veins
- C. Dependent edema
- D. Bradycardia
Correct Answer: A
Rationale: Postural hypotension is a common sign of extracellular fluid volume deficit due to decreased blood volume, leading to a drop in blood pressure upon standing. Distended neck veins, dependent edema, and bradycardia are not typically associated with extracellular fluid volume deficit. Distended neck veins are more indicative of fluid volume overload, dependent edema is a sign of fluid retention, and bradycardia is not a common finding in extracellular fluid volume deficit.
When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?
- A. Change the pouch as needed based on individual requirements.
- B. Apply the pouch only when the skin barrier is completely dry.
- C. Pat the peristomal skin dry after cleaning.
- D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
Correct Answer: D
Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.
A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
- A. Pain related to ischemia
- B. Risk for altered elimination: constipation
- C. Risk for complication: dysrhythmias
- D. Anxiety related to pain
Correct Answer: A
Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?
- A. Prolonged use does not typically cause dark concentrated urine.
- B. It is not necessary to take the medication on an empty stomach for optimal absorption.
- C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
- D. Drinking alcohol daily can cause drug-induced hepatitis.
Correct Answer: D
Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.