The nurse is caring for a comatose client with a Salem sump tube. Which action by the nurse is correct regarding care of this client?
Rationale:
C: assess the position of the Salem sump before each feeding. Ensuring the correct placement of the Salem sump tube is essential to prevent complications such as aspiration and to facilitate proper gastric drainage and feeding. Regular assessment helps maintain patient safety and effective treatment during tube feedings.
A: clamp the air vent during tube feedings. Clamping the air vent can create a vacuum effect, leading to potential complications such as gastric distention or aspiration, which could jeopardize patient safety.
B: place the client on the left side in a high-Fowler's position. Although positioning is important, a high-Fowler's position may not be suitable for comatose clients, who require specific positioning to prevent aspiration and ensure proper tube function.
D: infuse bolus feedings with a pump or by gently plunging into the stomach. Bolus feedings should be carefully administered to avoid complications; using a pump ensures controlled delivery, while plunging risks over-distention or aspiration.
The nurse is caring for a client whose lab results show triglycerides of 380 and cholesterol level of 240. Which foods would the nurse educate the client about including in his diet when he is discharged? Select all that apply.
Rationale:
A: Wheat toast with sugar-free jelly, grilled salmon seasoned with herbs, and an egg-white omelet with vegetables are beneficial choices, as they support heart health and help lower triglyceride levels.
D: Natural honey from a local farmer's market contains sugars, which can contribute to higher triglyceride levels, making it less suitable for managing the client's condition.
E: Plain grilled steak prepared with pepper only is high in saturated fats, which can negatively impact cholesterol levels and should be moderated in a heart-healthy diet.
The nurse is caring for a client who adheres to a lactovegetarian diet. Which meal tray would the nurse deliver to the client?
Rationale:
B: steamed vegetables with rice and apple slices. This meal tray aligns perfectly with a lactovegetarian diet by including plant-based foods while also incorporating dairy, which is acceptable for lactovegetarians who avoid meat and eggs.
A: chicken sandwich, brown rice, yogurt, and milk. The inclusion of chicken contradicts the principles of a lactovegetarian diet, which excludes all meat products.
C: scrambled eggs, cottage cheese, dry toast, and milk. The presence of scrambled eggs disqualifies this meal for a lactovegetarian, who does not consume any eggs.
D: baked zucchini, spinach salad with cheese, and yogurt. Although mostly plant-based, this option lacks sufficient variety and does not include a fruit component, which is important in a balanced lactovegetarian meal.
The clinic nurse is seeing a pregnant client who is expecting her first child. She complains of morning sickness and nasal stuffiness. The nurse recommends interventions to minimize discomfort from her symptoms. Which should the nurse recommend? Select all that apply.
Rationale:
Taking ginger pills to alleviate nausea, using a humidifier to help with congestion, eating dry crackers before getting out of bed in the morning, and using an over-the-counter nasal spray are effective recommendations for minimizing discomfort from morning sickness and nasal stuffiness during pregnancy.
B: Drink a full glass of water at each meal. Consuming large amounts of water during meals can lead to bloating and discomfort, which may exacerbate nausea rather than alleviate it.
E: Eat three regular meals each day to provide needed nutrients. Regular meals may not suit all pregnant individuals, especially those experiencing nausea; smaller, frequent meals are often more effective at managing symptoms.
A client has just returned from a cardiac catheterization with access via the femoral artery. Which position or activity should the nurse anticipate the health care provider will order for this client?
Rationale:
D: bed rest with head of bed at 30 degrees or less. This position minimizes strain on the femoral access site, helping to prevent complications such as bleeding or hematoma formation after cardiac catheterization.
A: bed rest with bathroom privileges. Allowing bathroom privileges could increase the risk of movement that may compromise the femoral access site's stability and safety.
B: bed rest with head of bed at 45 degrees. Elevating the head of the bed to this degree may increase pressure at the catheter insertion site, posing risks for complications.
C: ambulation to prevent blood clot formation. Immediate ambulation post-procedure could disrupt the femoral artery access site, increasing the likelihood of bleeding or clot formation at the insertion point.
E: up to chair with assistance if the client is steady on his feet. This option allows too much movement too soon, which can jeopardize the integrity of the femoral access site.
The nurse is caring for a client with sternal wires following a coronary artery bypass graft (CABG). The client complains of severe pain when coughing and deep breathing. What nonpharmacological measures can the nurse take to increase client comfort? Select all that apply.
Rationale:
Clients with sternal wires after CABG experience significant discomfort, so suggesting audio books or relaxing music (C), teaching pillow splinting techniques (D), encouraging meditation (E), and proper positioning (F) effectively alleviate pain and enhance comfort during coughing and deep breathing. These measures focus on distraction, support, and comfort without relying solely on medication.
A: apply hot packs to the sternum. Using heat on the sternum can exacerbate pain or discomfort, especially in postoperative clients, as it may increase swelling or irritation in the sensitive area.
B: give morphine PRN for pain before client coughs. While morphine can relieve pain, it does not represent a nonpharmacological measure, focusing instead on medication rather than alternative comfort strategies that promote client engagement.
The nurse is caring for a group of clients in a medical/surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers?
Rationale:
C: a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair. This client’s obesity contributes to increased pressure on bony prominences while sitting, heightening the risk of decubitus ulcers due to reduced mobility and circulation.
A: a 27-year-old client who fractured her arm playing volleyball. This client's recent fracture does not significantly impair mobility or pressure distribution, diminishing her risk for developing pressure ulcers.
B: a 6-year-old client on pelvic skin traction for muscle spasms. While traction can affect movement, the young age and overall resilience of children reduce the likelihood of skin breakdown compared to adults.
D: a 70-year-old client with heart failure who uses a cane for ambulation in the room and hall. Despite age being a factor, this client’s ability to ambulate decreases the prolonged pressure associated with ulcer formation.
The unit nurse is precepting a nursing student who is assisting a client with a femur fracture onto a fracture bedpan. Which action by the student nurse requires intervention by the unit nurse? Select all that apply.
Rationale:
The student nurse tries to lift the client onto the bedpan. This action requires intervention as it poses a risk of injury to both the client and the student due to the client's limited mobility from the femur fracture.
B: The student nurse positions the head of the bed between 30 and 45 degrees. This positioning is appropriate as it promotes comfort and facilitates the use of the bedpan without compromising safety.
C: The student nurse places the call light within reach and tells the client she will return shortly. Ensuring the call light is accessible supports the client's autonomy and safety, allowing them to communicate needs effectively.
E: The student nurse places the bedpan with the deeper end under the buttocks toward the sacrum. This placement is incorrect as it does not provide optimal support and comfort for the client, potentially leading to discomfort or complications.
The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply.
Rationale:
Maintain the head of bed in a high-Fowler's position during feedings and check under the adhesive tape on the nose daily to assess for skin breakdown.
High-Fowler's position facilitates better digestion and minimizes the risk of aspiration during tube feedings. Daily assessment under the adhesive tape ensures prompt identification and management of potential skin breakdown, promoting patient comfort and safety.
A: flush tube every 4 hours with hot water to maintain patency. Flushing with hot water is not standard practice; sterile saline is typically preferred to prevent irritation and ensure tube function.
B: allow the feeding and tubing to hang until empty, up to 48 hours. Tubing should not be left hanging for extended periods; this can increase the risk of contamination and infection.
D: check residuals and replace them unless the amount is greater than 300 mL. Residuals should be evaluated carefully; replacing them indiscriminately can lead to complications such as aspiration or delayed gastric emptying.
F: assess the bowel sounds before feeding, and feed at half the rate if bowel sounds are absent. Feeding at half the rate without bowel sounds may not be necessary; a complete assessment is crucial to determine appropriate feeding methods.
The nurse is preparing to discharge a client who was treated for tuberculosis. Which guidelines for home management should the nurse include in his discharge teaching? Select all that apply.
Rationale:
C: The medication regimen should be followed diligently as prescribed. Adhering to the medication regimen is crucial for effective treatment and preventing drug resistance in tuberculosis, ensuring the client’s recovery and minimizing transmission risk.
A: The client may resume his normal activities. Tuberculosis requires careful management; premature resumption of normal activities can lead to complications and transmission risks to others.
B: The family should maintain respiratory isolation at home. While precautions are essential, respiratory isolation is typically not necessary once the client is no longer contagious, especially with effective treatment.
D: The client may return to work when three sputum cultures are negative. Returning to work requires thorough evaluation of the client’s health status, including more than just the sputum cultures, to ensure safety.
E: The nurse should educate the client about the medication and possible side effects and their management. Educating clients on medication management and potential side effects is vital for adherence and recognizing issues early.
The nurse is caring for a client with deep vein thrombosis (DVT). Which should be included in the plan of care?
Rationale:
Bed rest with the affected extremity elevated should be included in the plan of care. Elevating the extremity reduces swelling and promotes venous return, which is essential in managing deep vein thrombosis effectively.
B: bed rest with the bed in reverse Trendelenburg does not facilitate proper venous drainage and may not effectively address swelling in the affected limb.
C: walking slowly in the hall with assistance to prevent pneumonia could exacerbate the condition by increasing the risk of dislodging a clot, which is counterproductive for DVT management.
D: sitting up in the chair for all meals and during visitation time may not provide adequate elevation for the affected extremity, potentially worsening swelling and discomfort related to DVT.
The nurse is caring for a client who refuses to get out of bed. He tells the nurse, 'I'm too tired to get up. I'm sick. I'm supposed to rest in the hospital.' For which complications of immobility does the nurse understand that the client is at risk? Select all that apply.
Rationale:
The client is at risk for urinary tract infection, orthostatic hypotension, muscular atrophy and foot drop, and increased length of hospitalization due to prolonged immobility.
Prolonged bed rest can lead to urinary stasis, increasing the risk of urinary tract infections. Additionally, immobility contributes to decreased muscle tone, resulting in orthostatic hypotension and muscular atrophy, while extending the hospitalization period due to complications.
A: decreased appetite Not mobilizing can affect metabolism and appetite, but this is not a primary consequence of immobility compared to other complications.
E: boredom, frustration, and anxiety Emotional responses may occur; however, these are not the primary physical complications associated with immobility and do not directly affect physical health outcomes.
The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse?
Rationale:
B: Ordering a neurology consult is crucial because the lack of movement in response to the foot stroke may indicate possible neurological issues. This assessment is vital for identifying any underlying conditions that require further investigation and intervention.
A: Taking the infant's vital signs does not address the immediate concern of the lack of movement, which suggests a potential neurological problem that needs prioritized evaluation.
C: Examining the infant's nose and ears does not relate directly to the observed lack of movement. This assessment would not provide relevant information regarding the infant's neurological status.
D: Asking about the infant's formula consumption is unrelated to the neurological assessment. While feeding is important, it does not address the critical concern of the infant's response to the foot stimulus.
The nurse is teaching a group of nursing students about proper client positioning. Which statement by a student nurse indicates an understanding of proper positioning?
Rationale:
Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed. This position facilitates easier breathing and promotes optimal lung expansion, reducing the risk of further respiratory distress.
A: A client receiving an enema should be placed on the right side in the Sims' position. The Sims' position is typically used for rectal examinations or procedures, not specifically for enemas.
B: A client with a below-the-knee amputation should be positioned with the affected limb elevated at a 45-degree angle. Elevating the limb too high may hinder circulation and could lead to complications during recovery.
D: Clients with a craniotomy should be positioned with the head of bed at a 20-degree angle with the head in a neutral, midline position. A higher elevation is generally recommended to reduce intracranial pressure effectively.