Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should:
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Solution
Answer A is correct. The nurse should replace the aspirate and administer the feeding because the amount aspirated was less than 50mL. Answers B and C are incorrect choices because the aspirate should not be discarded. Answer D is incorrect because the feeding should not be withheld.
A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because:
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Solution
Answer B is correct. Growth plates located in the epiphysis can be damaged by epiphyseal fractures. Answers A, C, and D are untrue statements; therefore, they are incorrect.
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:
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Solution
Answer D is correct. Burping the baby frequently throughout the feeding will help prevent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration.
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
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Solution
Answer C is correct. Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect choices because they would allow the urine to pool.
The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?
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Solution
Answer D is correct. Steak, baked potato, and tossed salad are lower in purine than the other choices. Liver, crab, and chicken are high in purine; therefore, answers A, B, and C are incorrect.
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
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Solution
Answer B is correct. The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thiamine and multivitamins are given to prevent Wernicke’s encephalopathy, not delirium tremens.
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
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Solution
Answer C is correct. Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect.
The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:
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Solution
Answer A is correct. Stool from the ileostomy contains digestive enzymes that can cause severe skin breakdown. Answer B contains contradictory information; therefore, it is incorrect. Answers C and D contain inaccurate statements; therefore, they are incorrect
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
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Solution
Answer B is correct. With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order.
A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:
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Solution
Answer B is correct. Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages.