A client has a small-bore nasoenteric feeding tube. The nurse assesses the following
vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22
breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula.
Give this one a try later!
, C
The client may have aspirated. The nurse should further assess the client's
respiratory and oxygenation status. The client may have another reason for
the abnormal vital signs, so the nurse should not pull out the tube before
performing other assessments. Adding blue dye to the tube feeding
formula is not recommended to check for aspiration. Slowing the feeding
down will not be helpful.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries
Give this one a try later!
C
Clients who are severely immune compromised or who have diabetes
mellitus are more prone to fungal urinary tract infection. The nurse should
assess for these factors. A physical examination and a post-void residual
may be needed, but not until further information is obtained. Travel to
foreign countries probably would not be as important, because even if
exposed, the client needs some degree of immune compromise to develop
a fungal urinary tract infection.
The nurse is assessing a client who had a stroke in the right cerebral hemisphere.
Which neurologic deficit does the nurse assess for in this client?
A) Agraphia
B) Aphasia
,C) Impaired olfaction
D) Impaired proprioception
Give this one a try later!
D
A stroke to the right cerebral hemisphere causes impaired visual and spatial
awareness. The client may present with impaired proprioception and may
be disoriented as to time and place. The right cerebral hemisphere does
not control speech, smell, or the client's ability to write.
The client was given 15 mg of morphine IM for postsurgical pain. When the nurse
checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory
rate of 10 breaths/min. What is the nurse's first action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push
Give this one a try later!
C
Many clients experience some degree of respiratory depression with
opioid analgesics. If the client can be aroused with minimally intrusive
techniques and the rate of respiration is increased spontaneously, no
further intervention is required.
The new nurse is caring for a client with a high temperature. Which action should the
nurse perform FIRST?
A) Obtaining a fan from central supply for the client's room
, B) Monitoring the client's temperature more often than ordered
C) Sponging the client while monitoring for shivering
D) Apply cool packs to the client's axillae and groin
Give this one a try later!
D
The use of fans is discouraged to promote cooling in a febrile client
because the fan can disperse pathogens. The other actions are
appropriate.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at
greatest risk for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic
Give this one a try later!
B
D5W contains no electrolytes. Because the client is not taking any food or
fluids by mouth, normal sodium excretion can lead to hyponatremia. The
antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is
essential to teach this client?
A) "Increase your intake of foods high in potassium."
B) "Avoid taking aspirin or aspirin-containing products."
vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22
breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula.
Give this one a try later!
, C
The client may have aspirated. The nurse should further assess the client's
respiratory and oxygenation status. The client may have another reason for
the abnormal vital signs, so the nurse should not pull out the tube before
performing other assessments. Adding blue dye to the tube feeding
formula is not recommended to check for aspiration. Slowing the feeding
down will not be helpful.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries
Give this one a try later!
C
Clients who are severely immune compromised or who have diabetes
mellitus are more prone to fungal urinary tract infection. The nurse should
assess for these factors. A physical examination and a post-void residual
may be needed, but not until further information is obtained. Travel to
foreign countries probably would not be as important, because even if
exposed, the client needs some degree of immune compromise to develop
a fungal urinary tract infection.
The nurse is assessing a client who had a stroke in the right cerebral hemisphere.
Which neurologic deficit does the nurse assess for in this client?
A) Agraphia
B) Aphasia
,C) Impaired olfaction
D) Impaired proprioception
Give this one a try later!
D
A stroke to the right cerebral hemisphere causes impaired visual and spatial
awareness. The client may present with impaired proprioception and may
be disoriented as to time and place. The right cerebral hemisphere does
not control speech, smell, or the client's ability to write.
The client was given 15 mg of morphine IM for postsurgical pain. When the nurse
checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory
rate of 10 breaths/min. What is the nurse's first action?
A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push
Give this one a try later!
C
Many clients experience some degree of respiratory depression with
opioid analgesics. If the client can be aroused with minimally intrusive
techniques and the rate of respiration is increased spontaneously, no
further intervention is required.
The new nurse is caring for a client with a high temperature. Which action should the
nurse perform FIRST?
A) Obtaining a fan from central supply for the client's room
, B) Monitoring the client's temperature more often than ordered
C) Sponging the client while monitoring for shivering
D) Apply cool packs to the client's axillae and groin
Give this one a try later!
D
The use of fans is discouraged to promote cooling in a febrile client
because the fan can disperse pathogens. The other actions are
appropriate.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at
greatest risk for developing hyponatremia?
A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic
Give this one a try later!
B
D5W contains no electrolytes. Because the client is not taking any food or
fluids by mouth, normal sodium excretion can lead to hyponatremia. The
antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is
essential to teach this client?
A) "Increase your intake of foods high in potassium."
B) "Avoid taking aspirin or aspirin-containing products."
