The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

Correct Answer: C

Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to

Correct Answer: B

Rationale: The correct answer is B: Montelukast (Singulair). Montelukast is a leukotriene receptor antagonist that helps prevent asthma exacerbations by reducing inflammation in the airways. It is used as a maintenance medication to control and prevent asthma symptoms. Diphenhydramine (A) is an antihistamine used for allergies, not asthma prevention. Albuterol sulfate (C) is a rescue inhaler used for acute asthma symptoms, not prevention. Epinephrine (D) is used for severe allergic reactions (anaphylaxis), not asthma prevention.

Correct Answer: A

Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.

Correct Answer: B

Rationale: The correct answer is B because assessing and promoting the patient's coping skills is essential in addressing the psychosocial needs of a patient with macular degeneration. By understanding how the patient is coping with the vision loss, the nurse can tailor interventions to support the patient effectively. This approach acknowledges the patient's emotional responses and helps them navigate the challenges associated with the condition. Choice A is incorrect as solely focusing on other senses may not address the psychological impact of vision loss. Choice C is incorrect as it dismisses the significant lifestyle changes the patient may experience. Choice D is incorrect as promoting hope for recovery may not be realistic in the case of irreversible conditions like macular degeneration.

Correct Answer: C

Rationale: The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake. Explanation for why the other choices are incorrect: A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting. B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it. D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.

Correct Answer: B

Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.

Correct Answer: A

Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications. Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.

Correct Answer: B

Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because: A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods. C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass. D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.

Correct Answer: C

Rationale: The correct answer is C: Venous thromboembolism. After a hysterectomy, patients are at increased risk for developing blood clots due to decreased mobility and pressure on the veins. Sitting for long periods can further increase this risk by slowing blood flow. Pudendal nerve damage (A) is not a common complication of hysterectomy. Fatigue (B) is a common postoperative symptom but not directly related to sitting for long periods. Hemorrhage (D) is a potential complication of hysterectomy but is not specifically related to sitting for long periods.