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Questions 158

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Question 1 of 5

A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:

Correct Answer: A

Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.

Question 2 of 5

A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a small-bore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:

Correct Answer: C

Rationale: A chest x-ray is the most reliable method to confirm small-bore feeding tube placement, as other methods may be inconclusive or unreliable.

Question 3 of 5

Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:

Correct Answer: A

Rationale: Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. Range of motion exercises are not appropriate to presenting symptoms. These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. Phenytoin is indicated for seizure activity mainly of neurological origin.

Question 4 of 5

A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?

Correct Answer: C

Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.

Question 5 of 5

A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?

Correct Answer: B

Rationale: Gas-forming foods such as cabbage should be avoided.

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