Question

1. A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take?

1. Discard the open can of formula after 36 hr.
2. Administer feeding at a slower rate.
3. Flush the tube with 10 mL of water after feedings.
4. Provide chilled formula.

2. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take?

1. Withhold the medication if the client does not appear to be in pain.
2. Withhold the medication if the client has a fever.
3. Document administration of the medication upon removal from the medication dispensing system.
4. Count the current number of unit doses available in the medication dispensing system.

3. A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?

1. Herpes zoster
2. Hypertension
3. Obesity
4. Hypothyroidism

4. A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?

1. Temperature 37.6^o C (99.7^o F)
2. Urinary output 20 mL/hr
3. Blood pressure 100 mm Hg
4. Serous drainage on abdominal dressing

5. A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury?

1. Place the bedside table at the foot of the bed.
2. Keep the television on during the night.
3. Assist the client to the toilet frequently.
4. Raise the side rails up when the client is in be

Answer 1

• b (Administer at a slow rate) A nurse is caring for a client with diarrhea and receiving intermittent enteral feeding.The following action should the nurse take is reduce the rate of the feeding because enteral feeding are used to patients who are able able to absorb and digest nutrients but are unable to ingest food.Use of enteral feeding can cause regurgitation,delay gastric emptying and malabsorption takes place reducing the rate feeding can minimize the risk for diarrhea.Intermittent enteral tube feeding can experience diarrhea because of the administration of hyperosmolar enteral feeding.
• c (Document administration of the, medication upon removal from the client medication dispensing system because over dose may leads to seizures respiratory depression,coma,syncope. The nurse should report the number of units should administer to the client.
• a(Herpes zoster) A nurse in a provider office is caring for a client who asks about using acupunture to manage for his Osteoarthritis pain.The nurse should identify condition as a contraindication for receiving this treatment is Skin problems or skin diseases because it may leads to skin infections.
• b(Urine output 20ml/min) A nurse in assessing the client for abdominal surgery.The nurse should report the urine output of 20ml/min because decreased urine output may cause kidney failure in the client with abdominal surgery.
• d( Raise the side rails up when the patient is in dementia and also use bed exit alarm system). To avoid the risk for client injury the nurse should provide bed side rails.Long term hospitals can use bed side rails to keep people safe.