The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?

Correct Answer: D

Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions. Summary of Incorrect Choices: A: Instilling nonliquid medications without diluting can increase the risk of tube clogging. B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube. C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.

Correct Answer: A

Rationale: The correct answer is A: Obtain an interpreter. This is the best action as it ensures effective communication and accurate understanding of the patient's history and needs. Using a professional interpreter maintains confidentiality, avoids misinterpretation, and promotes cultural sensitivity. Referring to a speech therapist (B) is not appropriate for language barriers. Letting a family member talk (C) may compromise privacy and accuracy. Finding a mental health nurse specialist (D) is not needed for language translation.

Correct Answer: A

Rationale: The correct answer is A: Wear a medical identification bracelet. This is important because in case of an emergency, such as an allergic reaction, medical professionals need to be aware of the child's severe food allergy quickly. The bracelet provides crucial information that can help in providing timely and appropriate medical care. B: Knowing how to use the antihistamine pen is also important in managing allergic reactions, but wearing a medical identification bracelet takes precedence as it provides immediate identification of the allergy. C: Knowing how to give injections of lidocaine is not relevant to managing a food allergy in a child. D: Avoiding live attenuated vaccinations may be necessary for individuals with certain allergies, but it is not directly related to educating parents about managing the child's food allergy.

Correct Answer: A

Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale: 1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process. 2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration. 3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection. 4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms. Summary: - B: Unlikely as there are no other signs of infection. - C: Unlikely as the pain is described as occasional and sharp. - D:

Correct Answer: D

Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.

Correct Answer: A

Rationale: Correct Answer: A - Care of the cervical collar Rationale: 1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support. 2. Proper care prevents complications and promotes healing. 3. It is a crucial aspect of discharge education to prevent injury and promote recovery. Summary of other choices: B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy. C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education. D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.

Correct Answer: A

Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions. Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range. Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up. Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.

Correct Answer: A

Rationale: The correct answer is A: Maintaining a closed urinary drainage system. This action prevents infection by reducing exposure to external pathogens. Step 1: A closed system minimizes the risk of contamination. Step 2: It prevents entry of bacteria into the urinary tract. Step 3: Regularly emptying the drainage bag helps maintain a closed system. Step 4: This action promotes patient safety and reduces infection risk. Summary: Choice B (strict clean technique) may reduce infection risk during catheter insertion but does not prevent infections post-insertion. Choice C (replacing drainage bag once per shift) increases infection risk due to frequent disconnection. Choice D (fully inflating catheter balloon) is unrelated to infection prevention.

Correct Answer: A

Rationale: The correct answer is A because taking time off from work to mourn allows the nurse to process their emotions and prevent burnout. This self-care step promotes mental well-being and helps prevent the nurse from being overwhelmed by their grief. Choice B is incorrect as it may prolong the grieving process and create a constant reminder of the loss. Choice C could potentially burden the patient's family with the nurse's grief, making it an inappropriate action. Choice D, attending the memorial service, may be emotionally challenging and may not provide the nurse with the necessary space to cope with their grief effectively.