Nokea
Which assessment finding would most likely indicate a complication of enteral tube feeding?
- A. Abdominal distension
- B. Weight gain
- C. Decreased bowel sounds
- D. Diarrhea
Correct Answer: A
Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.
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The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?
- A. Protect the client's feet from injury
- B. Apply a heating pad to affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct Answer: A
Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.
Which condition is commonly screened for in newborns using the Guthrie test?
- A. Phenylketonuria (PKU)
- B. Cystic fibrosis
- C. Down syndrome
- D. Sickle cell anemia
Correct Answer: A
Rationale: The Guthrie test is specifically designed to screen newborns for phenylketonuria (PKU), a metabolic disorder that can lead to intellectual disability if left untreated. Phenylketonuria is caused by the deficiency of an enzyme required to metabolize the amino acid phenylalanine. Screening for PKU in newborns is crucial as early diagnosis and intervention can prevent the severe consequences associated with the condition. Choices B, C, and D are incorrect as the Guthrie test is not used to screen for cystic fibrosis, Down syndrome, or sickle cell anemia.
A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse's best action?
- A. Administer a prescribed laxative.
- B. Encourage the client to increase fluid intake.
- C. Auscultate bowel sounds.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.
An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN who is taking the client's vital signs. What action should the PN implement?
- A. Notify the healthcare provider or charge nurse immediately
- B. Offer to reschedule the treatment for the following week
- C. Plan to monitor the client's vital signs every 30 minutes
- D. Reinforce the need for extra rest periods and plenty of sleep
Correct Answer: D
Rationale: When a client undergoing radiation therapy reports increasing fatigue, it is essential to address this common side effect. Educating the client on the importance of rest and sleep can help manage fatigue and promote recovery. Contacting the healthcare provider or charge nurse immediately may not be necessary unless fatigue is severe and other symptoms are present. Rescheduling the treatment or monitoring vital signs more frequently is not the priority in this situation.
When administering parenteral iron, which action would be inconsistent with proper administration?
- A. Using the Z-track method
- B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
- C. Not massaging the injection site
- D. Using the deltoid muscle for administration
Correct Answer: D
Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.