Nokea
When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct Answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
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Which of the tractions is used to treat fractures of the humerus?
- A. Bryant's traction
- B. Overhead suspension traction
- C. Thomas splint traction
- D. 90-90 traction
Correct Answer: B
Rationale: Humerus fractures require specific traction. Bryant's traction (choice A) treats femoral fractures in children. Overhead suspension traction (choice B) stabilizes humeral fractures, aligning via arm suspension. Thomas splint (choice C) is for femur fractures. 90-90 traction (choice D) suits femoral shaft issues. B is correct, standard for humerus. Nurses apply it, check alignment, and prevent skin breakdown, aiding healing.
Client perceptions about their health problems are:
- A. Objective data
- B. Observational recordings
- C. Aucilliary reports from the data collector
- D. Subjective data
Correct Answer: D
Rationale: Subjective data are clients' perceptions e.g., 'I feel dizzy' reported directly, capturing experiences unmeasurable by others. This contrasts with objective data (e.g., pulse), observable by nurses. Observational recordings are objective, like noting pallor, not perceptions. Ancillary reports (e.g., lab results) are objective, external data, not client-voiced. Subjective data's focus on personal input e.g., pain severity enriches assessment, guiding nurses to explore symptoms' impact (e.g., anxiety's role), making it vital for holistic care and the correct classification here.
All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except:
- A. Increased oxidative enzyme levels
- B. Alcohol taken with medication
- C. Medications containing magnesium
- D. Decreased serum albumin
Correct Answer: A
Rationale: Oxidative enzyme levels decrease with age, not increase, affecting drug metabolism.
Which of the following statement best describe nursing informatics?
- A. A type of surgery
- B. Use of technology in nursing
- C. A medical diagnosis
- D. A cultural practice
Correct Answer: B
Rationale: Nursing informatics is use of technology in nursing (B), per definition e.g., EHRs for care. Not surgery (A), diagnosis (C), culture (D) tech-focused. B best defines informatics' role, making it correct.
A client with celiac disease is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?
- A. I should avoid foods that contain gluten.
- B. I should increase my intake of foods high in gluten.
- C. I should avoid foods that contain lactose.
- D. I should increase my intake of foods high in lactose.
Correct Answer: A
Rationale: The correct answer is A: 'I should avoid foods that contain gluten.' Celiac disease requires the avoidance of gluten-containing foods to manage symptoms and prevent complications. Gluten is found in wheat, barley, and rye. Choices B, C, and D are incorrect as they do not align with the dietary requirements for managing celiac disease. Increasing intake of foods high in gluten or lactose would be detrimental for someone with celiac disease.