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Questions 164

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Question 1 of 5

As adult is admitted with bleeding esophageal varices, and a triple-lumen nasogastric tube is inserted and the balloons inflated. What should the nurse keep at the bedside because the client has this tube?

Correct Answer: C

Rationale: Scissors are kept at the bedside to cut and release the tube if the balloons cause airway obstruction or excessive pressure, a critical safety measure for triple-lumen tubes like the Sengstaken-Blakemore.

Question 2 of 5

The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?

Correct Answer: A

Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.

Question 3 of 5

A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?

Correct Answer: A

Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.

Question 4 of 5

Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?

Correct Answer: C

Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.

Question 5 of 5

When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?

Correct Answer: A

Rationale: Risk for injury: hemorrhage. Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices, can be life-threatening.

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