Nokea
Which of the following statements best explains why the nurse should evaluate gastric residual in administering the client's next enteral feeding?
- A. To determine how well nutrients are being absorbed
- B. To determine if the client is receiving enough feeding
- C. To prevent overdistention of the stomach
- D. To prevent mixing undigested formula with partially digested formula
Correct Answer: C
Rationale: Evaluating gastric residual prevents overdistention of the stomach, which can lead to aspiration or discomfort. It does not directly assess nutrient absorption or feeding adequacy.
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The nurse is caring for a client with a history of venous insufficiency. Which of the following interventions is most appropriate?
- A. Encourage prolonged standing.
- B. Apply compression stockings.
- C. Keep the legs in a dependent position.
- D. Limit fluid intake.
Correct Answer: B
Rationale: Compression stockings improve venous return and reduce swelling in venous insufficiency.
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
When assessing a 2-month-old infant, the nurse feels a 'click' when abducting the infant's left hip. Which of the following should the nurse do next?
- A. Document the finding as normal for a 2-month-old.
- B. Check the lengths of the femurs to determine if they are equal.
- C. Instruct the mother to keep the leg in an adducted position.
- D. Reschedule the child for a follow-up assessment in 3 weeks.
Correct Answer: B
Rationale: A 'click' during hip abduction suggests developmental dysplasia of the hip, so checking femur lengths helps confirm asymmetry for further evaluation.
A client with a history of cirrhosis is admitted with jaundice. The nurse should include which of the following in the plan of care?
- A. Monitor for signs of bleeding.
- B. Encourage a high-fat diet.
- C. Administer vitamin C.
- D. Restrict protein intake.
Correct Answer: A
Rationale: Jaundice in cirrhosis indicates liver dysfunction, increasing bleeding risk due to impaired clotting factor production.
A normal, healthy infant is brought to the clinic for the first immunization against polio. The nurse should administer this vaccine by what route?
- A. Oral route.
- B. I.M. route.
- C. Subcutaneous route.
- D. Intradermal route.
Correct Answer: A
Rationale: The polio vaccine for infants is administered orally (OPV) in many regions, though inactivated polio vaccine (IPV) is given intramuscularly in some settings. Based on the options, oral is correct.