A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

Correct Answer: B

Rationale: Fresh fruit is naturally low in sodium and is a suitable choice for a low-sodium diet. It provides essential nutrients without adding significant amounts of sodium, making it a healthy option for individuals following a low-sodium diet. Canned soup, pickles, and soy sauce are high in sodium content and should be avoided by individuals on a low-sodium diet. Canned soups are often loaded with added salt, pickles are preserved in brine containing high sodium levels, and soy sauce is a condiment with a high sodium content.

Correct Answer: A

Rationale: Mannitol, an osmotic diuretic, can cause hypotension (A) from fluid shifts and diuresis. Hyperkalemia (B), hyperglycemia (C), or bradycardia (D) are less common. A is correct. Rationale: BP drop risks perfusion; monitoring ensures safety, per pharmacology, critical in brain injury management.

Correct Answer: C

Rationale: Providing frequent oral care (C) is key with NPPV (e.g., CPAP/BiPAP), as high-flow air dries the mouth, risking sores or discomfort. Q4h SpO2 (A) isn't specific to NPPV. Q15min RR (B) is excessive. 1-2 L/min (D) doesn't apply to NPPV. Oral care enhances comfort, per critical care standards, vital for compliance.

Correct Answer: C

Rationale: Autogenic training (C) is self-suggestion or self-hypnosis, using phrases to induce relaxation (e.g., 'my arms are heavy'). Biofeedback (A) relies on machines, meditation (B) on focus, and visualization (D) on imagery not self-hypnosis. Autogenic training, per Schultz, shifts autonomic responses via mental cues, aligning with the definition, making C correct.

Correct Answer: C

Rationale: Assisting the client with early ambulation is crucial in preventing respiratory complications after abdominal surgery. Early ambulation helps to prevent conditions like atelectasis and pneumonia by promoting lung expansion and preventing pooling of respiratory secretions. It also aids in improving circulation, reducing the risk of deep vein thrombosis, and enhancing overall recovery. Instructing the client to exhale into an incentive spirometer (Choice A) is beneficial for lung expansion but is more focused on respiratory therapy rather than preventing complications. Repositioning the client every 8 hours (Choice B) is important for preventing pressure ulcers but is not directly related to preventing respiratory complications. Maintaining the client on bed rest for the first 48 hours (Choice D) can lead to complications such as atelectasis, pneumonia, and deep vein thrombosis due to decreased lung expansion and mobility.

Correct Answer: A

Rationale: Sterilization of culture media is critical in microbiology to eliminate contaminants. Autoclaving (choice A) uses moist heat under pressure (typically 121°C at 15 psi for 15-20 minutes) to kill bacteria, spores, and viruses, making it the gold standard for sterilizing liquid media like agar or broth. Boiling (choice B) at 100°C can kill vegetative bacteria but not heat-resistant spores, rendering it inadequate for complete sterilization. Hot air oven (choice C) employs dry heat (160-170°C for 2 hours) and is suitable for glassware, not liquid media, as it may evaporate or degrade nutrients. Ionizing radiation (choice D) is effective for heat-sensitive materials (e.g., plastics), but it's less common for routine media preparation due to cost and equipment needs. Autoclaving is the correct answer (A) because it ensures thorough sterilization of culture media, a process nurses and lab personnel rely on to maintain aseptic conditions for accurate diagnostic cultures.

Correct Answer: A

Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.

Correct Answer: D

Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.