Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
A. Observe the client's respiratory status.
When caring for a client with a decreased level of consciousness who is receiving continuous enteral feedings, the top priority is to ensure the client's airway and respiratory status are maintained. This is because a decreased level of consciousness can increase the risk of aspiration, which can lead to respiratory distress or compromise.
B. Monitor intake and output every 8 hr.
Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.
C. Elevate the head of the client's bed 30° to 45°.
Elevating the head of the client's bed to 30° to 45° helps reduce the risk of aspiration during feeding and is an important action, but it is not the highest priority in this scenario.
D. Check residual volume every 4 to 6 hr.
Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.
This question is an excerpt from Nurse Dive's nursing test bank - RN Ati fundamental of nursing proctored exam. Take the full exam now
Full Explanation
A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.
B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.
C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.
D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.
Similar Questions
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
A. The client who has a chest tube to water seal
A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. The client who has a tracheostomy tube attached to humidified oxygen
A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. The client who has an indwelling urinary catheter to gravity drainage
An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. The client who has a nasogastric (NG) tube to suction
A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
Full Explanation
A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?
A. Using a computer terminal in a non-public area
Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers
Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal
Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified health care worker from viewing a health record on the computer screen
Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
Full Explanation
A. Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
A. Report the incident to the charge nurse.
Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Wash the area of the puncture thoroughly with soap and water.
Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Go to employee health services.
Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Complete an incident report.
Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.
Full Explanation
A. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.