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Questions 163

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Question 1 of 5

An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?

Correct Answer: A

Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.

Question 2 of 5

The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

Correct Answer: C,D

Rationale:
To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.

Question 3 of 5

The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

Correct Answer: A

Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.

Question 4 of 5

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?

Correct Answer: C

Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.

Question 5 of 5

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?

Correct Answer: B

Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C,
D) are correct for subcutaneous administration.

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