a nurse is preparing to administer an enteral feeding through a gastrostomy tube before administering the feeding the nurse aspirates some stomach con
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

Correct answer: Administer the feeding as ordered

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

2. The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?

Correct answer: Implementation

Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.

3. To which of the following do the CDC Standard precautions recommendations apply?

Correct answer: All patients receiving care in hospitals

Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.

4. When assessing a patient’s pulse, which of the following characteristics would the nurse also notice?

Correct answer: Force

Rationale: When assessing a patient's pulse, the nurse should observe characteristics such as rate, rhythm, and force. Force refers to the strength or amplitude of the pulse, which provides important information about cardiac output. Pallor is the paleness of the skin and is not directly related to pulse assessment. Capillary refill time is used to assess peripheral perfusion and is not specifically part of pulse assessment. Timing in the cardiac cycle is a broader concept and not a characteristic directly assessed during a pulse examination. Therefore, choice A, 'Force,' is the correct answer as it aligns with the standard parameters evaluated during pulse assessment.

5. What is the primary purpose of a patient care meeting or conference?

Correct answer: how the healthcare team can best meet the patient's needs

Rationale: The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.

Similar Questions

The supervising RN asks you to bring the unit's collected lab specimens to the lab 'stat'. You should ______________.
Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?
Which of the following is one of the three smallest bones in the body?
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses