Nursing Elites

1. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

• A. Continuing to advance the tube to the desired distance
• B. Pulling the tube back slightly
• C. Checking the back of the pharynx using a tongue blade and flashlight.
• D. Instructing the client to breathe slowly and take sips of water.

Correct answer: A

Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.

2. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer?

• A. Janice, a 45 y.o. with a 25-year history of ulcerative colitis
• B. George, a 50 y.o. whose father died of colon cancer
• C. Herman, a 60 y.o. who follows a low-fat, high-fiber diet
• D. Sissy, a 72 y.o. with a history of breast cancer

Correct answer: C

Rationale: Herman, a 60 y.o. who follows a low-fat, high-fiber diet, has the fewest risk factors for colon cancer.

3. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct the patient to:

• A. Avoid the use of pain medication.
• B. Cough and deep breathe Q2H.
• C. Splint the incision if he can’t avoid sneezing or coughing.
• D. Apply heat to scrotal swelling.

Correct answer: C

Rationale: Instruct the patient to splint the incision if he can't avoid sneezing or coughing to minimize the risk of complications after heriorrhaphy.

4. A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?

• A. Have the client drink 1000 mL of water.
• B. Ask the client about possible allergies to iodine or shellfish.
• C. Administer an intravenous contrast agent the evening before the test.
• D. Administer tap-water enemas until clear.

Correct answer: B

Rationale: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur.

5. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

• A. Assessing the client's bowel sounds
• B. administration of pain medication every 4 hours
• C. Evaluating the client's response to antidiarrheal medications
• D. Maintaining intake and output records

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

Similar Questions