Nokea
Which of the following actions should the nurse plan to take?
- A. Flush the NG tube with 30 ml D.9% sodium chloride before and after medication.
- B. Maintain the head of the bed at a 20° angle.
- C. Advance the rate of the feeding every 2 hr.
- D. Measure gastric residual volumes every 4 hr
Correct Answer: D
Rationale: Measuring residuals prevents aspiration risks.
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure
- B. Compare the client's current weight with preprocedural weight
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedural weight. This is the most appropriate action to evaluate the effectiveness of the procedure because changes in weight can indicate fluid retention or loss, which are common outcomes of many procedures. This comparison helps assess if the procedure had the desired effect on the client's fluid status.
Examine for leakage at the site of the procedure (A) is not the best action to evaluate the procedure's effectiveness as leakage may not always correlate with the overall success of the procedure. Confirming that the client is able to urinate (C) is important but may not directly indicate the effectiveness of the procedure. Checking the client's serum albumin levels (D) is relevant for assessing nutritional status but may not directly evaluate the procedure's effectiveness.
The nurse should first address the client’s-------followed by the client’s-----
- A. safety
- B. abrasions
- C. hygiene
- D. heart rate
- E. pain
- F. BMI
Correct Answer: E,A
Rationale: Addressing pain and safety prioritizes client needs.
Which of the following actions should the nurse take?
- A. Infuse the medication over 10 min
- B. Instruct the client to notify the provider if diarrhea develops
- C. Refrigerate the medication after reconstitution.
- D. Check the client for a sulfa allergy.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to notify the provider if diarrhea develops. This action is important because diarrhea can be a potential side effect of medication, especially antibiotics, and may indicate a serious adverse reaction. It is crucial for the client to inform the provider promptly to prevent complications.
Choice A is incorrect as it refers to a specific administration instruction for a medication, not related to client monitoring. Choice C is incorrect as it pertains to storage of medication, not client education. Choice D is incorrect as it focuses on assessing for a specific allergy, not related to ongoing client monitoring.
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
- A. Posting swallowing precautions at the head of the client’s bed
- B. Noting changes in the treatment plan in the client's medical record
- C. Recording the client's progress in the nurses’ notes
- D. Having interdisciplinary team meetings for the client on a regular basis.
Correct Answer: D
Rationale: Rationale for the Correct Answer (D): Having interdisciplinary team meetings for the client on a regular basis is the best action to promote communication among staff caring for the client. This approach ensures that all healthcare team members are regularly updated on the client's condition, progress, and treatment plan. It allows for collaborative decision-making and coordination of care, leading to a holistic and effective approach to managing the client's needs. Additionally, it provides an opportunity for staff to discuss any challenges, share insights, and adjust interventions as needed to optimize the client's outcomes.
Summary of Incorrect Choices:
A: Posting swallowing precautions at the head of the client's bed is important for safety but does not directly promote communication among staff.
B: Noting changes in the treatment plan in the client's medical record is essential for documentation but may not facilitate real-time communication among staff members.
C: Recording the client's progress in the nurses' notes is necessary for tracking the client's status but does not ensure comprehensive communication among all team