Exam 1- Clinical Decision Making Questions And Answers

A nurses' aid has finished feeding a frail, older client and has lowered the head of the bed at the client's request for a nap. Which action by the nurse is most appropriate? a. Document how the client tolerated the feeding and amount of intake. b. Listen to the client's lungs and have the aid get a set of vital signs. c. Raise the head of the client's bed to at least 30 degrees for the next hour. d. Ask the client if he/she would like to have the ordered sleeping medication. - ANS c. Raise the head of the client's bed to at least 30 degrees for the next hour. A nurse in a rehabilitation facility is preparing to admit a new patient from an inpatient hospital who had a stroke. Which action by the nurse is most appropriate? a. Ensure there is a suction machine and tubing in the room. b. Request a dietary consult for an appropriate diet. c. Request blue dye from the pharmacy to add to the client's food. d. Consult with the provider and request a swallowing study. - ANS a. Ensure there is a suction machine and tubing in the room. R: Suction equipment should be available for any client who is at high risk of aspiration. If the client aspirates, it is important to suction immediately. Blue dye (which used to be added to tube feeding formulas) should not be used as it has been shown to cause death in clients who do aspirate. There is no indication that this client needs a special diet or a swallowing study at this time. . A nurse is preparing to administer a tube feeding through a small bore feeding tube that has been in place for several days. Which action by the nurse is most appropriate? a. Instill air through the tube and ausculate for air sounds in the client's stomach. b. Measure the distance of the tube outside the body, comparing it to the chart. c. Check the pH of the gastric residual using nitrazine paper. d. Call radiology and request a chest x-ray to confirm placement of the tube. - ANS b. Measure the distance of the tube outside the body, comparing it to the chart. R: When a small bore feeding tube is placed, an x-ray is obtained to determine correct placement. Thereafter the best way to check placement is to compare the distance of the tube outside the body with what was charted when placement was confirmed. If the nurse questions placement, an x-ray should be ordered. Ausculating for the whooshing of air in the client's stomach is not a reliable indicator of placement. Checking pH is helpful, but may not be accurate for a client on tube feeding, proton pump inhibitors or antacids, or has blood in the aspirate. Also, it is often difficult to obtain aspirate from a small-bore feeding tube. A nurses' aid is working with an unresponsive client receiving a tube feeding. Which action by the nurse requires immediate intervention? a. Recording the client's daily weight in the chart b. Reconnecting the enteral tube feeding line when it comes apart c. Maintaining the head of the client's bed at 30-45 degrees d. Turning the tube feeding off to reposition the client. - ANS b. Reconnecting the enteral tube feeding line when it comes apart R: Unlicensed personnel should be taught never to reconnect dislodged lines. The aid should find the nurse for this task. Recording the weight and keeping the head of the bed elevated are correct actions. While turning the tube feeding off to reposition the client is generally not needed, this action does not compromise the client's safety and the nurse does not need to intervene immediately. An older client has had a stroke and needs some assistance with feeding. Which instruction by the nurse to the nurses' aid is most important? a. "Be sure to brush the client's teeth after meals." b. "Please document what the client eats in the chart." c. "Weigh the client daily at the same time on the same scale." d. "Help the client choose foods he/she prefers for meals." - ANS a. "Be sure to brush the client's teeth after meals." R: All options are appropriate for the care of this client. However, good oral care has been shown to be effective in preventing health care facility-acquired pneumonia from aspiration of bacterial or fungal contamination of the mouth. The nurse assessing clients for constipation would be least concerned with the client having which assessment finding? a. Hypoactive bowel sounds