Nokea
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
- A. Provide the client with oral hygiene.
- B. Offer the client liquids to drink.
- C. Encourage the client to cough and deep breathe.
- D. Auscultate the client's bowel sounds.
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
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The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:
- A. Impaired physical mobility.
- B. Impaired skin integrity.
- C. Ineffective coping.
- D. Risk for injury.
Correct Answer: D
Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). Which of the following nursing interventions is most appropriate at this time?
- A. Encourage a large fluid intake.
- B. Assess for return of bowel sounds.
- C. Assist with morning care.
- D. Administer a laxative as ordered.
Correct Answer: A
Rationale: Encouraging a large fluid intake post-IVP helps flush the contrast dye from the kidneys, reducing the risk of nephrotoxicity.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about dietary modifications. Which of the following foods should the client limit?
- A. Whole grains.
- B. Sugary beverages.
- C. Lean proteins.
- D. Non-starchy vegetables.
Correct Answer: B
Rationale: Sugary beverages should be limited in type 2 diabetes to prevent blood glucose spikes.
A client with a history of stroke is at risk for aspiration. Which intervention is most appropriate?
- A. Offer thin liquids.
- B. Position upright during meals.
- C. Provide large bites of food.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk by aiding swallowing and gravity.