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When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?
- A. Flush the NG tube with water before each feeding.
- B. Check the placement of the NG tube before each feeding.
- C. Elevate the head of the bed to 30-45 degrees.
- D. Provide the patient with oral care every 4 hours.
Correct Answer: C
Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.
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How should a healthcare provider respond when a patient expresses concerns about the side effects of a prescribed medication?
- A. Reassure the patient that side effects are rare.
- B. Discuss the benefits and risks of the medication with the patient.
- C. Encourage the patient to speak to the pharmacist.
- D. Refer the patient to another healthcare provider for information.
Correct Answer: B
Rationale: When a patient expresses concerns about medication side effects, it is crucial for the healthcare provider to discuss the benefits and risks of the medication with the patient. This approach helps the patient make an informed decision about their treatment. Choice A is incorrect because dismissing the patient's concerns by reassuring them that side effects are rare may not address the patient's specific worries. Choice C, while pharmacists can provide valuable information, the primary responsibility lies with the healthcare provider. Choice D is incorrect as referring the patient to another healthcare provider may disrupt continuity of care and not address the patient's concerns effectively.
A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?
- A. The nursing student wears a gown to change the bed of an incontinent client.
- B. The nursing student washes hands before making contact with the client.
- C. The nursing student washes her hands before glove removal after emptying a Foley bag.
- D. The nursing student changes gloves between tasks and procedures.
Correct Answer: C
Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.
When considering a bone marrow transplant for a client with leukemia, which ethical principle pertains to minimizing harm to the client?
- A. Justice
- B. Nonmaleficence
- C. Autonomy
- D. Beneficence
Correct Answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the obligation to do no harm, making it crucial in medical decision-making. In the context of a bone marrow transplant for a client with leukemia, the primary concern is to minimize harm and avoid causing any unnecessary suffering or adverse effects. Choices A, C, and D are incorrect: Justice relates to fairness in resource allocation and treatment decisions, Autonomy involves respecting the patient's right to make decisions about their own care, and Beneficence refers to the obligation to act in the patient's best interest and promote their well-being, which may involve some level of risk or harm for overall benefit.
A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying semiprone.
- B. Patient is lying on side.
- C. Patient is lying on abdomen.
- D. Patient is lying on back.
Correct Answer: B
Rationale: The correct answer is B because the lateral position means lying on the side with body weight on the dependent hip and shoulder. Choice A is incorrect as 'semiprone' means lying on the abdomen with one leg flexed. Choice C is incorrect as 'prone' means lying face down. Choice D is incorrect as 'supine' means lying on the back.
A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?
- A. Allow the patient to pull up on the nurse's arm.
- B. Place a gait belt around the patient for support.
- C. Have the patient push off the chair with their hands.
- D. Ask the patient to lift themselves up without support.
Correct Answer: B
Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.