Nokea
Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.
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During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?
- A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
- B. Remind the client to walk carefully down the stairs until reaching a lower floor.
- C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
- D. Open the closest fire doors to facilitate the evacuation of ambulatory clients.
Correct Answer: B
Rationale: During a fire evacuation, it is crucial for ambulatory clients to be reminded to walk carefully down the stairs. This helps ensure the safety of the client by preventing falls or injuries during the evacuation process. Directing the client to proceed cautiously down the stairs until reaching a lower floor provides necessary guidance to promote a safe evacuation process. Choice A is incorrect because assigning unlicensed assistive personnel to transport the client via a wheelchair may delay the evacuation process and increase the risk of injury. Choice C is incorrect as it distracts the ambulatory client from evacuating safely by involving them in assisting another client. Choice D is incorrect as opening fire doors may not be the most appropriate action at that moment; prioritizing safe evacuation procedures for ambulatory clients is essential.
After ensuring correct tube placement, what action should the nurse take next when administering medications through a nasogastric tube (NGT) connected to suction?
- A. Clamp the tube for 20 minutes.
- B. Flush the tube with water.
- C. Administer the medications as prescribed.
- D. Crush the tablets and dissolve in sterile water.
Correct Answer: B
Rationale: After ensuring the correct placement of the NGT, the nurse should flush the tube with water to prevent any obstructions and ensure proper medication delivery. Flushing the tube is essential before, after, and in between each medication administration. Clamping the tube for 20 minutes should be done after all medications are administered to prevent clogging. Administering medications as prescribed and preparing medications by crushing tablets and dissolving them in sterile water should only be done after the tube has been appropriately flushed to maintain its patency and effectiveness.
The client is weak from inactivity due to a 2-week hospitalization. In planning care for the client, which range of motion (ROM) exercises should the nurse include?
- A. Passive ROM exercises to all joints on all extremities four times a day.
- B. Active ROM exercises to both arms and legs two or three times a day.
- C. Active ROM exercises with weights twice a day, 20 repetitions each.
- D. Passive ROM exercises to the point of resistance and slightly beyond.
Correct Answer: B
Rationale: Active ROM exercises are preferred over passive ROM to restore strength. Performing them on both arms and legs two or three times a day is effective in promoting muscle strength and mobility without the need for external assistance. Choice A is incorrect as passive ROM exercises may not help in restoring strength. Choice C is not recommended as using weights may be too strenuous for a weak client. Choice D is incorrect as passive ROM exercises to the point of resistance and slightly beyond may cause discomfort or injury to the weak client.
When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct Answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
A client is admitted with a diagnosis of fluid volume deficit. Which clinical finding would the nurse expect?
- A. Bounding pulse
- B. Bradycardia
- C. Oliguria
- D. Dry mucous membranes
Correct Answer: D
Rationale: Dry mucous membranes (D) are a common clinical finding indicating fluid volume deficit. In dehydration, there is insufficient fluid in the body, leading to dry mucous membranes due to decreased saliva production. Bounding pulse (A) is associated with fluid volume excess, not deficit. Bradycardia (B) and oliguria (C) are not typical clinical findings of fluid volume deficit but may be seen in fluid volume excess or other conditions.