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Questions 158

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Question 1 of 5

The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

Correct Answer: A

Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.

Question 2 of 5

The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:

Correct Answer: A

Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.

Question 3 of 5

The best size cathlon for administration of a blood transfusion to a six-year-old is:

Correct Answer: D

Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.

Question 4 of 5

The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:

Correct Answer: B

Rationale: Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. The estrogen-progesterone assay test is used to identify present tumors being fed from an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.

Question 5 of 5

A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

Correct Answer: B

Rationale: When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.

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