Which assessment data would provide the most accurate determination of proper placement of a
nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after ...
which assessment data would provide the most accurate determination of proper placement of a nasogastric tube a aspirating gastric contents to assure a ph value of 4 or less b hearing air pass
Nursing Fundamentals HESI Pre Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x -ray obtained after the tubing was inserted. D) Checking the remaini ng length of tubing to ensure that the correct length was inserted. - C) Examining a chest x -ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tu bing is properly placed is (C). (D) is not an indicator of proper placement When assisting an 82 -year -old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet - B) Upper torso The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Which action is most important for the nurse to im plement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first. - C) Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). An adult male client wi th a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary t herapy and western medicine can be effective for you. - A) It is important that you continue your medication while learning to meditate The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medicati ons must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured The nurse plans to obtain health assessment information from a primary source. Whi ch option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records - A) Client A primary source of information for a health assessment is the client (A). (B, C , and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. The nurse is instructing a client with high cholesterol about diet and life style modif ication. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intak e of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase. - C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an importan t diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, bu t should be restricted to lean cuts of red meat and smaller portions (2 -ounce servings). The low density lipoproteins (D) need to decrease rather than increase Examination of a client complaining of itching on his right arm reveals a rash made up of multi ple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpo int to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when rec ording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated les ions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the ne xt day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clea r liquid diet be okay after surgery? - A) What is your daily calorie consumption? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long -term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yell ow secretions return. What action should the nurse implement next?
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