Nokea
A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube.
Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.
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A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.
A nurse is caring for a client who is one hour postpartum and unable to urinate.
Which of the following actions should the nurse take?
- A. Place the client's hand in warm water.
- B. Perform in-and-out catheterization.
- C. Encourage the client to void in the shower.
- D. Apply fundal pressure to stimulate urination.
Correct Answer: C
Rationale: The correct action is C: Encourage the client to void in the shower. This option promotes relaxation and can help facilitate urination. Warm water can help relax the muscles and promote voiding without invasive procedures like catheterization (B) or fundal pressure (D), which can be uncomfortable and potentially harmful. Voiding in the shower also maintains privacy and dignity for the client. Choices E, F, and G are not relevant to promoting urination.
The nurse is continuing to care for the client.
Provider Prescriptions
Day 1, 1100:
Lithium carbonate 600 mg PO BID
The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.
- A. The client engages in quiet activities in their room
- B. The client slept 5 hr. the previous night
- C. The client consumes 8 oz of high-calorie fluids each hour
- D. The client takes 2 short naps during the day
- E. The client appears to listen to unseen others.
Correct Answer: A,B,C,D
Rationale: Improved behaviors include engaging in quiet activities, sleeping adequately, consuming fluids, and napping appropriately. Listening to unseen others indicates ongoing psychosis.
A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Keep a calorie count for foods and beverages
- B. Provide a high-calorie, high-protein diet
- C. Encourage a low-fat diet to prevent digestive issues
- D. Restrict oral intake and provide IV fluids only
Correct Answer: B
Rationale: The correct answer is B: Provide a high-calorie, high-protein diet. This intervention supports the client's nutritional requirements by ensuring they receive adequate energy and protein for healing and overall health. High-calorie intake can prevent malnutrition, while high-protein intake supports tissue repair and immune function. Keeping a calorie count (A) is helpful but not as crucial as ensuring the client receives enough calories and protein. Encouraging a low-fat diet (C) is not the priority when aiming to meet nutritional requirements. Restricting oral intake (D) and providing IV fluids only can lead to malnutrition and should be avoided.