A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

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Question 1 of 5

A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.

Question 2 of 5

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Correct Answer: A

Rationale: A client with low blood glucose levels needs immediate assessment to ensure stabilization. Hypoglycemia can lead to serious complications if not addressed promptly. The other options do not present immediate life-threatening situations that require urgent assessment. Option B can be attended to after addressing the client with low blood glucose levels. Option C can be managed based on the infusion rate and the client's condition. Option D, although important, can be assessed after ensuring the client with low blood glucose levels is stable.

Question 3 of 5

A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: B

Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.

Question 4 of 5

A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider instruct the client to avoid?

Correct Answer: C

Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.

Question 5 of 5

A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?

Correct Answer: B

Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.

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