Nokea
What is the nurse’s evaluation of Mr. Singer not testing for proper placement of his nasogastric tube?
- A. Mr. Singer must be stopped before the instillation of the feeding
- B. There is no possibility that the tube will get into Mr. Singer’s trachea
- C. If Mr. Singer shows no breathing difficulties, he can proceed with his feeding
- D. The greatest danger for Mr. Singer is the aspiration of the feeding into his lung
Correct Answer: D
Rationale: Aspiration poses a serious risk if the tube is misplaced.
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Mrs. Blakely had an intracapsular extraction yesterday. Early this morning she complained of eye pain and nausea after breakfast while continuing to complain of eye pain. Your analysis of the situation is that Mrs. Blakely is
- A. unable to tolerate a regular diet this soon postoperatively
- B. allergic to the pain medication
- C. experiencing increased intraocular pressure
- D. exhibiting symptoms of postoperative infection
Correct Answer: C
Rationale: Severe eye pain accompanied by nausea following cataract surgery suggests elevated intraocular pressure, which must be addressed promptly to prevent complications.
When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?
- A. A client who is scheduled for an abdominal x-ray and is awaiting transport
- B. A client who has a prescription for discharge
- C. A client who received oral pain medication 30 minutes ago
- D. A client who told an assistive personnel he is short of breath
Correct Answer: D
Rationale: The correct answer is D because a client who is experiencing shortness of breath may be in a critical condition requiring immediate intervention to prevent respiratory distress or failure. This is a high-priority issue that needs prompt assessment and intervention to ensure the client's safety.
A: A client awaiting transport for an abdominal x-ray is not in an immediate life-threatening situation.
B: A client with a prescription for discharge can typically wait as the discharge process can be coordinated by other healthcare team members.
C: A client who received oral pain medication 30 minutes ago is not experiencing an urgent or life-threatening situation, as the medication may take time to alleviate pain.
What action assumes greatest priority for Mr. Walker with productive cough, dull percussion notes, and rhonchi?
- A. Determine if Mr. Smith has a history of COPD
- B. Monitor respiratory status for increasing dyspnea
- C. Discuss ways to prevent pneumonia
- D. Obtain a physician’s order for sedatives
Correct Answer: B
Rationale: Monitoring for worsening respiratory distress is critical.
Pain has been defined as “whatever the person experiencing the pain says it is, existing whenever the patient says it does.” This definition is problematic for the nurse when caring for which type of patient?
- A. A patient placed on a ventilator
- B. A patient with a history of opioid addiction
- C. A patient with decreased cognitive function
- D. A patient with pain resulting from severe trauma
Correct Answer: C
Rationale: The correct answer is C. Patients with decreased cognitive function may have difficulty communicating their pain, making this definition challenging.
What stage of shock is the client experiencing if they exhibit confusion, lethargy, and decreased urine production?
- A. Initial stage
- B. Compensatory stage
- C. Decompensation stage
- D. Irreversible stage
Correct Answer: C
Rationale: These symptoms indicate decompensation, where the body can no longer compensate for inadequate perfusion.