Question

4. Before administering a tube feeding, what action should be completed? Select all that apply. a. Check residual b. Flush with feeding solution c. Place in Fowlers position d. Document in chart e. Check tube placement 5. A student nurse is observing a CNA take care of a patient with abnormal body temperature at the hospital. When does the student nurse intervene when the CNA does which of the following activities? a. Monitors the patient's temperature at least every four hours or PRN b. Encourages the patient to drink fluids c. Covers the patient with more blankets, closes the room doors. d. Further assess for possible site of localized infection and reports to the nurse 6. The best nursing intervention when attempting to clear the lungs is: a. Cough and deep breathe once each 4 hours b. Incentive spirometer 10 times per hour c. Sit in the chair 2 times per day d. Increase fluid intake 7. Upon taking the patient's oral temperature and the results of 102 degrees. What would you expect the pulse and respiration to be? a. Pulse decreased, respirations decreased b. Pulse increased, respirations decreased c. Pulse decreased, respirations increased d. Pulse increased, respirations increased 8. To ensure that the nursing students are getting the best reception of sound, the nursing instructor informs the students that the earpieces of the stethoscope should follow the contour of the ear canal, pointing them where? a. Away from your face when the stethoscope is in place b. Towards your forehead when the stethoscope is in place c. Parallel to the temporal lobe of the head d. Towards the nasal area when the stereoscope is in place 9. The patient's has a history of hypertension. Which blood pressure value below would be consistent with this diagnosis? a. 128/72 b. 146/80

Answer 1

4. Before administering a tube feeding

check for residual by aspirating the tube and look for aspirated stomach contents.It also indicate the feeding tolerance by the patient.

Patient should be in up right position (fowlers position) to prevent chance of aspiration of feed

Check tube placement by aspirating the stomach content for gastric secretions and check the pH using a pH indicator. the value will be 0-5.

Flushing the tube can be done with sterile water or water prior, in between ,and after feeding but flushing with feeding solution prior to start feeding is not recommended.

Documentation of procedure should be done after the feeding.

Thus the answers are,a , c , and e.

5. Monitoring patient temperature every four hours, encouraging the patient to drink more fluids, and further assessment for localized infection and reporting to nurse is necessary actions in caring patient with abnormal body temperature. But covering the patient with blankets and closing the room doors will increase the patient body temperature, thus the student nurse has to intervene and this action should be avoided.

So, answer is c.

6. Cough and deep breath improves circulation and oxygenation and helps to dilates airway. Incentive spirometer and sitting in chair 2 times helps to relax the lung and thereby ease the breathing. Increase the fluid intake liquedify the sputum and helps to clear the lung.

Thus answer is Increase fluid intake

7. Increase in body temperature causes increase in heart rate approximately 10 beats per minutes for each degree elevation of temperature. Elevated body temperature also increases the respiratory rate

hence answer is d. Pulse increased, respiration increased.

9. Earpieces of stethoscope should point towards the bridge of the nose to clearly fill the ear canal and permits unobstructed sound pathways

Answer is d. Towards the nasal area when stethoscope in place