the nurse is preparing to administer 10 ml of liquid potassium chloride through a feeding tube followed by 10 ml of liquid acetaminophen which action
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Nursing Elites

NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

2. Which consideration is the most accurate when applying the principles of mental health?

Correct answer: D

Rationale: Emotional health is enhanced when an individual feels a sense of control over themselves and their surroundings, fostering security, reducing anxiety, and promoting optimal functioning. While some emotionally ill individuals may reject help initially, many are in distress and acknowledge the need for psychological support. Some seek care based on positive past experiences or the attention received. Additionally, individuals with excellent cognitive function may face challenges in problem-solving due to emotional or psychological barriers. Not all individuals with mental illness exhibit socially inappropriate behavior; it is a misconception that mental illness is solely characterized by such signs and symptoms. Therefore, the most accurate consideration among the choices is that emotional health thrives when there is a feeling of mastery over oneself and the environment.

3. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?

Correct answer: B

Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.

4. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

5. What action would be most appropriate for the nurse to minimize agitation in a disturbed client?

Correct answer: C

Rationale: The most appropriate action to minimize agitation in a disturbed client is to limit unnecessary interactions. This approach helps reduce stimulation, thus decreasing agitation. Constant staff contact can lead to increased stimulation and agitation. Increasing environmental sensory stimulation can overwhelm the client's senses and escalate agitation. Discussing suspicions may not be beneficial as not all disturbed clients are suspicious and the client may not be in a state to engage in such discussions effectively.

Similar Questions

A client who has multiple sclerosis is admitted to the hospital with increasingly frequent and severe exacerbations. One day, the client's partner confides to the nurse, 'Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home.' After listening to the partner's concerns, which response would the nurse make?
Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?
A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?
A client with generalized anxiety disorder presents with restlessness and fatigue. Which additional clinical manifestation would the nurse monitor for?
Which of the following is a nursing intervention for a client who is experiencing an acute panic attack?

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