Question: A nurse is caring for a client who has a nasogastric tube in place. Which action by the

nurse is appropriate when administering medication through the tube?

 A) Crushing enteric-coated tablets and mixing them with water before administering

 B) Administering all medications together to minimize tube manipulation

 C) Flushing the tube with 15-30 mL of water before and after each medication

 D) Administering medications directly without dilution to ensure full absorption

 Answer: C) Flushing the tube with 15-30 mL of water before and after each medication

 Rationale: Flushing the tube with water before and after medication administration helps

prevent clogging and ensures proper delivery of the medication.

Question: A nurse is assessing a client who has a history of chronic obstructive pulmonary disease

(COPD). Which finding should the nurse recognize as an early indication of hypoxemia?

 A) Cyanosis

 B) Restlessness

 C) Bradypnea

 D) Elevated blood pressure

 Answer: B) Restlessness

 Rationale: Restlessness is an early sign of hypoxemia as the body attempts to compensate for

inadequate oxygenation.

Question: When caring for a client with a chest tube, which assessment finding requires

immediate intervention by the nurse?

 A) Continuous bubbling in the water-seal chamber

 B) Drainage system below the level of the client's chest

 C) Loose connections in the drainage tubing

 D) Presence of gentle tidaling in the water-seal chamber during inhalation and exhalation

 Answer: A) Continuous bubbling in the water-seal chamber

 Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which requires

immediate intervention to prevent complications.

Question: A nurse is providing discharge teaching to a client with a new colostomy. Which

statement by the client indicates a need for further education?

 A) "I should avoid eating high-fiber foods to prevent blockage of the stoma."

 B) "I will empty the ostomy pouch when it is one-third to one-half full."

 C) "I can use a hair dryer on a low, cool setting to dry the skin around the stoma."

 D) "I will consume plenty of fluids to help prevent dehydration and thickening of the stool."

 Answer: A) "I should avoid eating high-fiber foods to prevent blockage of the stoma."

 Rationale: High-fiber foods are important for colostomy patients to promote proper stool

consistency and prevent blockage.