Nokea
Your client has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
- A. Constipation: The provision of a high fiber diet
- B. Urinary pH changes: Encouraging ample oral fluid intake
- C. Aspiration: Maintaining the client in at least a 30 degree angle
- D. Aspiration: Maintaining the client in at least a 90 degree angle
Correct Answer: C
Rationale: Maintaining a 30-45 degree angle during tube feedings reduces the risk of aspiration by preventing reflux of gastric contents.
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Select the arterial blood gas that you would report to the client's physician because it is not within normal parameters and it is also a significant change for the client.
- A. PaO2: 65 mm Hg
- B. PaCO2: 40 mm Hg
- C. Arterial blood pH: 7.39
- D. SaO2: 96%
Correct Answer: A
Rationale: PaO2 of 65 mm Hg is below the normal range (75-100 mm Hg), indicating hypoxemia, which requires reporting.
A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.
- A. I have been so nauseous.
- B. I am having so much trouble with diarrhea.
- C. I have not had a menstrual period in 2 months.
- D. I have to go to the restroom to urinate all the time.
- E. I have been going to the health club regularly because I have so much energy.
Correct Answer: A,C,D
Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.
The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?
- A. You can drive after being seizure-free for 6 months.
- B. You can drive if you take your medication regularly.
- C. You can drive with a passenger at all times.
- D. You can drive during the daytime only.
Correct Answer: A
Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.
A client with a history of type 1 diabetes is prescribed insulin aspart (NovoLog). The nurse should instruct the client to:
- A. Take the insulin 5–10 minutes before meals.
- B. Mix the insulin with long-acting insulin.
- C. Take the insulin at bedtime.
- D. Stop the insulin if blood glucose normalizes.
Correct Answer: A
Rationale: Insulin aspart, a rapid-acting insulin, is taken 5–10 minutes before meals for prandial coverage.
A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response?
- A. I know how you feel, but the medication will make your child feel better.'
- B. I can't let you do this without calling your physician first.'
- C. Can you tell me why you want to take your child home now?'
- D. I can imagine how hard this is for you, but it's not what's best for the child.'
Correct Answer: C
Rationale: Asking the mother to explain her reasons encourages open communication and helps the nurse understand her concerns, facilitating appropriate support or intervention.