A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?

Correct Answer: B

Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.

Correct Answer: C

Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.

Correct Answer: A

Rationale: Urinary hesitancy occurs when a client has difficulty starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. Oliguria refers to decreased urine output, retention is the inability to empty the bladder fully, and urgency is the sudden and strong need to urinate.

Correct Answer: C

Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.

Correct Answer: C

Rationale: Before administering immunizations to children, it is crucial to assess for contraindications. A depressed immune system, such as that seen in conditions like HIV or due to chemotherapy, is a significant contraindication. Immunizations may not be safe or effective in children with compromised immune systems. Mild cold symptoms, although not ideal, are not a contraindication for routine immunizations. Chronic asthma, while a consideration, is not a direct contraindication for routine immunizations. Allergy to eggs is a contraindication for specific vaccines, such as influenza vaccine that is grown in eggs, but it is not a contraindication for all immunizations.