The nurse is assessing the placement of a feeding tube to prevent aspiration of continuous feeding supplements. Using the aspiration technique, the nurse obtains a watery, straw-colored fluid and recognizes that this aspirate is most likely:
A) Gastric fluid
B) Pleural fluid
C) Fluid from the lungs
D) Contents from the small intestine
Ans: B
Feedback: Gastric fluid may be grassy green, brown, clear, or colorless. An aspirate from the lungs may be off-white or tan mucous. Pleural fluid is watery and usually straw colored.
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A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?
A) Passive range of motion exercises for the upper and lower extremities B) Early ambulation and the use of compression stockings C) Incentive spirometry and deep breathing and coughing exercises D) Maintenance of SpO2 levels ?90% using supplementary oxygen
An older patient must learn to administer a medication using a device that requires manual dexterity. The patient becomes frustrated and expresses lack of self-confidence in performing this task. Which action will the nurse perform next?
a. Ask the patient to keep trying until the skill is learned. b. Provide written instructions with illustrations showing each step of the skill. c. Schedule multiple sessions and practice each step separately. d. Teach the procedure to family members who can administer the medication for the patient.
A client with paranoid schizophrenia is being prepared for discharge. Which client statement verifies to a nurse that discharge is appropriate?
A) "They are all out to get me." B) "Thank you for being kind to me." C) "I think my roommate is a spy." D) "I don't want anyone to take my stuff."
The nurse was very busy and unfamiliar with a new medication, but administered it anyway. Later the nurse looked up the medication. How does the nurse manager evaluate this behavior?
A. This was acceptable as long as the nurse looked up the action and side effects of the drug later. B. An error could have occurred because the nurse was unfamiliar with the medication. C. The nurse manager was partially at fault because the nursing unit was understaffed and the nurse was too busy. D. An error did occur because the nurse could have administered the medication via the incorrect route.