SOLVED QUESTIONS
◉ The healthcare provider prescribes an IV infusion of 1000 ml of
Ringer's Lactate w/ 30 units of Pitocin to run in over 4 hours for a
client who has just delivered a 10 pound infant by cesarean section.
The tubing has been changed to a 20 gtt/ml administration set. The
nurse plans to set the flow rate at how many gtt/min? Answer: 83
gtt/min
◉ Which assessment data provides the most accurate determination
of proper placement of a nasogastric tube? Answer: Examining a
chest x-ray obtained after the tubing was inserted
◉ Three days following a surgery, a male client observes his
colostomy for the first time. He becomes quite upset and tells the
nurse that it is much bigger than he expected. What is the best
response by the nurse?
A. Reassure the client that he will become accustomed to the stoma
appearance in time.
B. Instruct the client that the stoma will become much smaller when
the initial swelling diminishes.
C. Offer to contact a member of the local ostomy support group to
help him with his concerns.
,D. Encourage the client to handle the stoma equipment to gain
confidence with the procedure. Answer: B. Instruct the client that
the stoma will become smaller when the initial swelling diminishes
(Postoperative swelling causes enlargement of the stoma. The nurse
can teach the client that the stoma will become smaller when
swelling is diminished (B). This will help reduce the client's anxiety
and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken
after the nurse provides pertinent teaching. The client is not yet
demonstrating readiness to learn colostomy care. (D)
◉ A female client with a nasogastric tube attached to low suction
states that she is nauseated. The nurse assesses that there has been
no drainage through the nasogastric tube in the last two hours. What
action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.
Answer: B. Reposition the client on her side. (The immediate
priority is to determine if the tube is functioning correctly, which
would then relieve the client's nausea. The least invasive
intervention (B) should be attempted first, followed by (A and C),
unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require an antiemetic (D))
,◉ A hospitalized male client is receiving nasogastric tube feedings
via a small-bore tube and a continuous pump infusion. He reports
that he had a bad bout of severe coughing a few minutes ago, but
feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this
time.
B. Stop the feeding, explain to the family why it is being stopped, and
notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid
withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium
for gurgling. Answer: C. After clearing the tube with 30 ml of air,
check the pH of fluid withdrawn from the tube.
◉ A male client tells the nurse that he does not know where he is or
what year it is. What data should the nurse document that is most
accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time Answer: D. is disoriented to place
and time (The client is exhibiting disorientation (D). (A) refers to
memory of the distant past. The client is able to express himself
without difficulty (B), and does not demonstrate diminished
attention span. (C).
, ◉ A client with chronic kidney disease (CKD) selects a scrambled
egg for his breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote
absorption.
D. Encourage the client to attend classes on dietary management of
CKD. Answer: A. Commend the client for selecting a high biologic
value protein. (Foods such as eggs and milk (A) are high biologic
proteins which are allowed because they are complete proteins and
supply the essential amino acids that are necessary for growth and
cell repair. Orange juice is rich in potassium and should not be
encouraged. The client has made a good diet choice so (D) is not
necessary.)
◉ When assisting an 82 year old client to ambulate, it is important
for the nurse to realize that the center of gravity for an elderly
person is the-- Answer: Upper torso (The center of gravity for adults
is the hips. However, as the person grows older, a stooped posture is
common because of the changes from osteoporosis and normal bone
degeneration, and the knees, hips, and elbows flex. This stooped
posture results in the upper torso becoming the center of gravity for
older persons.)