Nokea
Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
You may also like to solve these questions
Available is diphenhydramine 50 mg/mL. How many ml should the nurse administer? (Round to the nearest tenth)
Correct Answer: 0.6
Rationale: To determine the correct amount of diphenhydramine to administer, we can use the formula: Volume (mL) = Desired dose (mg) / Concentration (mg/mL). In this case, the desired dose is 50 mg and the concentration is 50 mg/mL. So, Volume = 50 mg / 50 mg/mL = 1 mL. Since we need to round to the nearest tenth, the correct answer is 0.6 mL. This is because 1 mL is equivalent to 50 mg, and since we only need to administer 50 mg, we use 0.6 mL. Other choices are incorrect as they do not adhere to the calculation based on the concentration and desired dose.
Which of the following actions should the nurse take first?
- A. Ask the client if he is considering harming himself.
- B. Encourage the client to attend a group therapy session.
- C. Administer an antidepressant to the client.
- D. Assist the client in completing his ADLs.
Correct Answer: A
Rationale: The correct answer is A. Asking the client if he is considering harming himself should be the first action because it assesses the client's immediate safety. This step is crucial in identifying any potential suicidal ideation and implementing appropriate interventions to ensure the client's well-being. Encouraging group therapy (B), administering medication (C), and assisting with ADLs (D) are important interventions but should come after addressing the client's safety concerns. It is essential to prioritize actions that address the most critical needs first to provide effective and timely care.
The nurse should immediately report which of the following findings to the provider?
- A. Rhinorrhea
- B. Pharyngitis
- C. Coughing
- D. Tachypnea
Correct Answer: D
Rationale: The correct answer is D: Tachypnea. Tachypnea, which is rapid breathing, can indicate respiratory distress or an underlying serious condition that requires immediate attention. Reporting this finding promptly is crucial to ensure timely intervention. Rhinorrhea, pharyngitis, and coughing are common symptoms that may not require urgent attention as they can be managed symptomatically. In summary, tachypnea is the most concerning symptom that warrants immediate reporting, while the other choices are less urgent and can be addressed in due course.
Which of the following instructions should the nurse include in the teaching?
- A. Apply bactericidal ointment to lesions.
- B. Administer acyclovir PO two times per day.
- C. Soak hairbrushes in boiling water for 10 min.
- D. Seal soft toys in a plastic bag for 14 days.
Correct Answer: A
Rationale: The correct answer is A: Apply bactericidal ointment to lesions. This instruction is essential to prevent secondary bacterial infection in lesions caused by herpes zoster. The ointment will help to keep the lesions clean and prevent bacterial growth. Administering acyclovir helps treat the viral infection but does not prevent bacterial infection. Soaking hairbrushes and sealing soft toys are not directly related to preventing infection in the lesions. Overall, the focus should be on proper wound care to prevent complications.
The nurse should teach the parents to take which of the following actions during a seizure?
- A. Minimize movement of the limbs.
- B. Clear the area of hard objects.
- C. Place the child in a prone position.
- D. Insert a tongue blade between the teeth.
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.