Nokea
Which of the following clinical findings is expected in a patient who has undergone gastric lavage and prolonged vomiting?
- A. Decreased serum pH
- B. Increased serum bicarbonate level
- C. Increased serum oxygen level
- D. Decreased serum osmotic level
Correct Answer: A
Rationale: Prolonged vomiting and gastric lavage lose stomach acid (HCl), causing metabolic alkalosis elevated pH, not decreased (acidosis). Bicarbonate rises as the body compensates, not oxygen or osmolarity, which are unrelated. Nurses monitor for alkalosis symptoms (e.g., tetany), correcting with fluids like saline, restoring acid-base balance disrupted by gastric content loss.
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The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:
- A. Record the heart rate and call the physician
- B. Record the heart rate and administer the medication
- C. Administer the medication and recheck the heart rate in 15 minutes
- D. Hold the medication and recheck the heart rate in 30 minutes
Correct Answer: B
Rationale: For a 6-month-old, an apical pulse of 100 beats per minute falls within the normal range (80-150 bpm), indicating it's safe to administer digoxin, a cardiac glycoside for heart defects, without delay. Recording and calling the physician or holding the dose isn't warranted unless the rate drops below 90-100 bpm (per pediatric guidelines). Rechecking post-administration isn't standard unless symptoms arise. Nurses document and proceed, ensuring timely therapy while monitoring for toxicity signs like bradycardia later.
When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct Answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.
Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior?
- A. Approach him in a calm manner
- B. Provide opportunities to express feelings
- C. Maintain eye contact with the client
- D. Isolate the client from others
Correct Answer: C
Rationale: Maintaining eye contact (C) is least effective with aggressive clients; it can escalate tension, per de-escalation guidelines. Calm approach (A), expression (B), and isolation (D) soothe or manage behavior. Eye contact may provoke, making C incorrect.
Which of the following statement clearly defines therapeutic communication?
- A. Therapeutic communication is an interaction process which is primarily directed by the nurse
- B. It conveys feeling of warmth, acceptance and empathy from the nurse to a patient in relaxed atmosphere
- C. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals
- D. Therapeutic communication is an assessment component of the nursing process
Correct Answer: C
Rationale: Therapeutic communication (C) is reciprocal, trust-based, and goal-oriented, per Peplau, identifying needs and setting mutual goals. Nurse-directed (A) lacks reciprocity, warmth (B) is partial, assessment (D) narrows scope. C fully defines it, making it correct.