Nokea
Which of the following statements about nasoenteric tubes is correct?
- A. The tube cannot be attached to suction.
- B. The tube contains a soft rubber bag filled with mercury.
- C. The tube is taped securely to the client's cheek after insertion.
- D. The tube can have its placement determined only by auscultation.
Correct Answer: C
Rationale: Nasoenteric tubes are taped securely to the client's cheek to prevent dislodgement. They can be attached to suction, do not typically use mercury today, and placement is confirmed by methods like X-ray, not just auscultation. CN: Physiological adaptation; CL: Apply
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A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
- A. Reinforce the aide's use of this intervention over the bony prominences.
- B. Explain that massage is effective because it improves blood flow to the area.
- C. Inform the aide that massage is even more effective when combined with lotion during the massage.
- D. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug?
- A. The drug's execution peaks in 2 hours.
- B. Maximum dosage is not achieved until 3 to 4 days after starting the medication.
- C. Effects of the drug continue for 4 to 5 days after discontinuing the medication.
- D. Protamine sulfate is the antidote for warfarin.
- E. I should have my blood levels tested periodically.
Correct Answer: B,C,E
Rationale: Warfarin's maximum effect takes 3-4 days (B), its effects persist 4-5 days after stopping (C), and periodic blood tests (e.g., INR) are required (E). Peak action is not 2 hours, and protamine sulfate is the antidote for heparin, not warfarin.
A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply.
- A. Aerobic activity
- B. Strength training
- C. Weight control
- D. Stress management
Correct Answer: A,C,D
Rationale: Rationales: A) Aerobic activity (e.g., walking) improves circulation and reduces clot recurrence. C) Weight control decreases venous pressure and clot risk. D) Stress management reduces sympathetic activation, aiding vascular health. B) Strength training is less critical for clot management and may be contraindicated initially.
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.