a client with a nasogastric tube in place following gastric surgery reports nausea what is the most appropriate nursing action
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Quizlet

1. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?

Correct answer: C

Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.

2. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.

3. A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

Correct answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

4. To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

Correct answer: A

Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.

5. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning?

Correct answer: C

Rationale: The correct answer is C. Use of accessory muscles is the most concerning finding in a client with COPD experiencing an exacerbation. This indicates increased work of breathing and can be a sign of respiratory failure, requiring immediate intervention. Oxygen saturation of 90% is low but not as concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute can be within normal limits. Inspiratory crackles may be present in COPD due to airway inflammation but are not as concerning as the use of accessory muscles.

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