Nokea
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
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Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.
The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of asthma
- B. The client takes furosemide twice daily
- C. The client has a history of alcohol use disorder
- D. The client takes vitamin C daily
Correct Answer: A
Rationale: The correct answer is A: The client has a history of asthma. Lavender can trigger asthma symptoms due to its volatile organic compounds. People with asthma may experience worsened symptoms or even asthma attacks when exposed to lavender. Asthma is a contraindication as it can lead to serious health complications.
Explanation for other choices:
B: The client takes furosemide twice daily - Furosemide is a diuretic and does not interact significantly with lavender.
C: The client has a history of alcohol use disorder - Alcohol use disorder does not directly contraindicate the use of lavender.
D: The client takes vitamin C daily - Vitamin C does not interact significantly with lavender.