When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

The urine meter attached to the urinary drainage bag is completely full.

A feeding is infusing at 40 mL/hour through an enteral feeding tube.

There is a large dependent loop in the client's urinary drainage tubing.

Purulent drainage is present around the insertion site of the feeding tube.

Answer and Explanation

The Correct Answer is C

A. The urine meter attached to the urinary drainage bag is completely full. While this observation requires attention, it does not pose an immediate risk to the client's safety. The nurse should
empty the urine meter promptly to prevent overflow.

B.   A feeding is infusing at 40 mL/hour through an enteral feeding tube. This rate of infusion is within the typical range for enteral feedings and does not indicate an immediate safety concern. However, the nurse should assess the client's tolerance to the feeding.
C.   There is a large dependent loop in the client's urinary drainage tubing. A large dependent loop in the urinary drainage tubing can lead to urinary stasis and increase the risk of urinary tract
infections or catheter-associated complications. It requires immediate intervention to prevent complications.
D.   Purulent drainage is present around the insertion site of the feeding tube. While purulent drainage indicates a potential infection at the insertion site, it may not require immediate
intervention unless the client exhibits signs of systemic infection such as fever or increased white blood cell count.

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Correct Answer is C

Explanation

A. Cheese products. Vegans do not consume any animal products, including dairy, so cheese products are not suitable for a vegan diet.
B. Egg white products. Vegans avoid all animal-derived foods, including eggs, so egg white products are also not suitable.
C. Soybean products. Soybeans are a versatile plant-based protein source that can be used in various forms such as tofu, tempeh, and edamame. These products are essential in a vegan diet as they provide a good source of protein and other nutrients that might otherwise be lacking.
D. Shellfish products. Vegans do not consume any animal products, including shellfish, making this option inappropriate for a vegan diet.

A. Insert a portion of the tablet into the tube and apply gentle pressure. B. Consult with the pharmacist about a liquid form of the medication C. Dissolve the medication in sterile water and use gravity to administer. D. Crush the medication and dilute with water before pouring into the tube.

Correct Answer is B

Explanation

A. Inserting a portion of the tablet into the tube and applying gentle pressure may not ensure proper dissolution, potentially leading to clogging or incomplete administration.
B. Consulting with the pharmacist about a liquid form of the medication is the best course of action. Enteric-coated tablets are formulated to release the medication in the small intestine, and crushing or dissolving them can alter their effectiveness or cause irritation.
C. Dissolving the medication in sterile water and using gravity to administer may not adequately address the enteric coating, risking medication inefficacy or irritation.
D. Crushing the medication and diluting it with water before pouring into the tube is not recommended for enteric-coated tablets, as it may compromise their effectiveness and lead to adverse effects.

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When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

Correct Answer is C

Explanation

The nurse is administering a client's medications through a feeding tube. One of the medications is an enteric-coated tablet. Which action would be best for the nurse to take?

Correct Answer is B

Explanation

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