Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?
A. Keep the patient in a low Fowler's position when at rest.
Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.
B. Connect the tube to continuous wall suction when not in use.
Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.
C. Confirm placement of the tube prior to each medication administration.
This statement is correct. Confirming placement of the tube prior to each medication administration is crucial to ensure safe and effective delivery of medications and nutrition.
D. Have the patient sip cool water to stimulate saliva production.
Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.
Choice C reason:
This statement is correct. Confirming placement of the tube prior to each medication
administration is crucial to ensure safe and effective delivery of medications and nutrition.
Choice D reason:
Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.
Similar Questions
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?
A. "The laxative helps eliminate the barium."
This statement is correct. The laxative helps eliminate the barium contrast material from the body after a barium swallow procedure.
B. "The laxative is the protocol at this facility."
Simply stating that it is protocol does not provide the client with a clear understanding of the rationale for the laxative.
C. "The laxative makes the barium turn brown."
This statement does not accurately explain the purpose of the laxative after a barium swallow.
D. "The laxative will prevent the absorption of magnesium."
The laxative's primary purpose in this context is to aid in the elimination of barium, not to prevent magnesium absorption.
Full Explanation
Choice A reason:
This statement is correct. The laxative helps eliminate the barium contrast material from the body after a barium swallow procedure.
Choice B reason:
Simply stating that it is protocol does not provide the client with a clear understanding of the rationale for the laxative.
Choice C reason:
This statement does not accurately explain the purpose of the laxative after a barium swallow.
Choice D reason:
The laxative's primary purpose in this context is to aid in the elimination of barium, not to prevent magnesium absorption.
A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
A. Left upper quadrant
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
B. Right upper quadrant
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
C. Right lower quadrant
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
D. Left upper quadrant
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Full Explanation
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
A. Asterixis
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
B. Fetor hepaticus
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
C. Palmar erythema
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
D. Constructional apraxia
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
Full Explanation
Choice A reason:
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
Choice B reason:
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
Choice C reason:
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
Choice D reason:
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.