NUR 125 Final Exam Fall

Correct Answer:Water helps clear the tube so it doesn't get clogged.

Detailed Explanation:

 Water helps clear the tube so it doesn't get clogged.

This is the most accurate and appropriate response. Flushing the NG tube with water after administering formula helps prevent clogging by clearing any residual formula from the tube. This is essential for maintaining tube patency and ensuring that future feedings or medications can be delivered without obstruction.

Why the other options are incorrect:

 Flushing helps make sure the tube stays in place.

Flushing the tube does not play a role in keeping it in place. Tube placement is secured by external fixation devices or tape and must be verified routinely, especially before feedings.

This will help you get enough fluids.

While some water may contribute to overall hydration, the primary purpose of flushing in this context is to prevent clogging, not hydration. If hydration is the goal, a specific volume of water would be prescribed as part of the feeding plan.

Adding water makes the formula less concentrated.

Water is not added to dilute the formula during the flushing step. Enteral formula is typically prepared at a prescribed concentration, and flushing water is not meant to alter this concentration but rather to maintain tube patency.

Summary:

 The nurse should explain that flushing with water is done to prevent the NG tube from clogging after feedings. The correct response is  Water helps clear the tube so it doesn't get clogged, and the other choices either misrepresent the purpose or focus on secondary effects not relevant to the specific procedure. 

 Correct Answer: Yogurt

Explanation

Yogurt is not permitted on a clear liquid diet because it is an opaque, dairy-based food. A clear liquid diet consists of transparent, liquid foods that leave no residue and are easily digested, allowing the gastrointestinal tract to rest or be prepared for procedures. Since yogurt is not transparent, it does not meet the criteria for a clear liquid and indicates that the client needs further teaching.

Why The Other Options Are Incorrect

Gelatin:

Gelatin (such as plain or flavored varieties like Jell-O) is a standard clear liquid because it is transparent and melts to a liquid at body temperature. It is often included in clear liquid diets.

Popsicle:

A popsicle, especially one made from clear juice or flavored water (without dairy or pulp), is also appropriate for a clear liquid diet. It provides fluids and a small amount of energy, and it melts into a clear liquid.

Broth:

Broth (such as chicken, beef, or vegetable broth) is a clear liquid when strained. It is commonly included in clear liquid diets because it is hydrating and provides electrolytes and minimal calories.

Summary

Yogurt is not allowed on a clear liquid diet because it is an opaque, dairy product. Appropriate clear liquids include gelatin, popsicles, and broth, which are transparent and easily digested. Clients should be taught to avoid foods like yogurt until they transition to a full liquid or soft diet.

 Correct Answer: Temporary urinary retention

Detailed Explanation of the Correct Answer:

Temporary urinary retention

This is the correct answer because temporary urinary retention is a common and expected outcome after the removal of an indwelling urinary catheter, especially in older adults. The bladder may temporarily have difficulty resuming normal function due to the loss of detrusor muscle tone or disruption of normal voiding cues. The nurse should assess for bladder distention and monitor time to first void, typically expecting urination within 6 to 8 hours.

Explanation of Incorrect Options:

 Blood-tinged urine

Blood-tinged urine is not a common or expected outcome after short-term catheterization (such as 2 days). While slight trauma could cause this, it should be reported and evaluated as it may indicate urethral or bladder trauma.

 Urinary frequency for several days

While mild urgency may occur initially, persistent urinary frequency for several days is not expected and could suggest infection or irritation. This would require further assessment and is not a normal outcome.

Highly concentrated urine

The concentration of urine depends more on the hydration status of the patient than on catheter removal. It is not specifically related to the catheterization period or expected post-removal.

Summary:

The expected outcome after the removal of a urinary catheter, especially in older adults, is temporary urinary retention due to bladder muscle incoordination or decreased tone. This condition typically resolves, but the nurse should monitor for the return of normal voiding. Other signs like blood in urine, persistent frequency, or high concentration are not typical and may indicate a need for further evaluation.

Correct Answers: 

Keep the call light in a consistent place within the client's reach

Inform the client of location of foods on the meal tray

Knock on the client’s door before entering the room

Detailed Explanation of Each Correct Answer:

Keep the call light in a consistent place within the client's reach

This promotes independence and safety. Visually impaired clients benefit from knowing where essential items are consistently located so they can access them without assistance.

Inform the client of location of foods on the meal tray

Describing the placement of food using a clock-face reference (e.g., "your chicken is at 6 o'clock") helps the client feed themselves without relying on others.

Knock on the client’s door before entering the room

This is a respectful and appropriate way to alert the client using auditory cues, allowing them to prepare for your entrance and maintain a sense of privacy and awareness.

Why the Incorrect Options Are Wrong:

Assist the client to the bathroom by walking behind the client

This method is unsafe. The correct approach is to offer your elbow and guide the client while walking slightly ahead so they can follow safely and comfortably.

Use another sense, such as hearing, by speaking to the client in a louder voice

Speaking louder is not necessary and may be inappropriate. Visual impairment does not imply hearing loss. Communication should be clear and at a normal volume unless hearing impairment is present.

Summary:

The nurse should support the visually impaired client’s independence by keeping the call light in a predictable place, describing food locations clearly, and knocking before entering the room. The nurse should not speak unnecessarily loudly or walk behind the client.

Correct Answer: Naloxone

Explanation

Naloxone is the antidote for opioid toxicity. It is an opioid antagonist that rapidly reverses the effects of opioids, including life-threatening respiratory depression, which is evidenced here by a respiratory rate of 6 breaths/min (well below the normal range of 12–20/min). Naloxone works by competing with opioids at receptor sites in the central nervous system, quickly restoring normal respiratory function. It can be administered IV, IM, subcutaneously, or intranasally in emergencies. In a client with opioid overdose, administering naloxone is the priority life-saving intervention.

Why The Other Options Are Incorrect

Protamine:

Protamine is used to reverse the effects of heparin, an anticoagulant. It has no effect on opioids or respiratory depression related to opioid use.

Flumazenil:

Flumazenil is the reversal agent for benzodiazepine toxicity (e.g., lorazepam, diazepam), not opioids. It is ineffective and inappropriate for treating opioid-induced respiratory depression.

Epinephrine:

Epinephrine is typically used in anaphylaxis or cardiac arrest due to its vasoconstrictive and bronchodilating effects. It does not reverse opioid toxicity and is not the drug of choice in this scenario.

Summary

Naloxone is the correct medication to reverse opioid toxicity, especially in the presence of severely decreased respiratory rate. Other agents like protamine, flumazenil, and epinephrine are used for different toxicities or emergencies and do not counteract opioid effects.

Correct Answer: A (retinol)

Explanation 

Vitamin A (retinol) is essential for maintaining normal vision, particularly night vision. It is a fat-soluble vitamin involved in the formation of rhodopsin, a pigment in the retina that allows the eyes to adjust in low-light conditions.

A deficiency in vitamin A can lead to night blindness (nyctalopia), which is often the earliest symptom of deficiency. In severe cases, it may progress to xerophthalmia and corneal damage, especially in malnourished individuals or those with fat absorption issues.

Why The Other Options Are Incorrect

B complex: The B vitamins are water-soluble and play roles in energy metabolism, nerve function, and red blood cell production, but they are not related to night vision. Deficiencies in B vitamins may cause symptoms such as fatigue, anemia, or neurological issues, but not difficulty seeing at night.

 D: Vitamin D is important for calcium absorption and bone health, preventing rickets in children and osteomalacia in adults. It does not affect visual function, particularly night vision.

 K: Vitamin K is necessary for blood clotting. A deficiency can lead to prolonged bleeding or bruising, but it does not cause visual disturbances or night blindness.

Summary

The client’s difficulty seeing at night strongly suggests a deficiency in vitamin A (retinol), which is crucial for night vision. Vitamins B, D, and K do not play direct roles in vision, particularly in dark environments.

Correct Answer: Walk to a safe area.

Explanation

The nurse’s first priority in the event of a fire is to ensure personal and client safety by removing individuals from immediate danger. This aligns with the RACE acronym used in fire safety protocol:

R – Rescue anyone in immediate danger

A – Alarm (activate the fire alarm)

C – Contain the fire by closing doors

E – Extinguish or evacuate

By walking to a safe area, the nurse initiates the “Rescue” step, removing themselves (and potentially clients) from harm’s way. This must be done before any other actions to ensure survival and safety.

Why The Other Options Are Incorrect

Close all the doors:

This is part of the “Contain” step in the RACE acronym and helps prevent the spread of smoke and flames. However, it should be done after rescuing people from danger. Closing doors while people are still in danger zones delays evacuation and increases risk.

Stay close to the ground:

While this helps avoid inhaling smoke (since smoke rises), it is not the first priority unless the nurse is trapped and trying to escape. The initial action should be to move to a safe area, not simply drop to the floor.

 Wrap clients in blankets:

Wrapping clients in blankets may be helpful after evacuation, especially if they are exposed to cold or smoke, but it is not a first-line action. It delays immediate removal from danger, which is more critical in a fire situation.

Summary

The first action in response to a fire or smoke is to walk to a safe area, in line with the “Rescue” step of fire response. Closing doors, staying low, and using blankets are secondary interventions that support safety but do not take precedence over immediate evacuation from danger.

 Correct Answer: Cluster medication administration times as much as possible.

EXPLANATION

 Cluster medication administration times as much as possible.

 For older adult patients, especially those who are forgetful or have mild cognitive impairment, simplifying the medication regimen is one of the most effective ways to promote adherence. By clustering doses (e.g., giving medications once or twice daily instead of multiple times throughout the day), the nurse can reduce the complexity and burden of the regimen, making it easier for the patient to remember and comply with. This approach is especially important for patients managing multiple medications (polypharmacy).

WHY THE OTHER OPTIONS ARE INCORRECT

Ask the patient to share the teaching with a neighbor or friend soon after discharge.

While encouraging patients to discuss what they've learned can reinforce understanding, asking them to share with a neighbor or friend does not directly promote adherence, especially if the person they share it with is not involved in their care. Also, forgetful patients may not remember or follow through with this step.

Give the patient detailed written information about each drug.

While written information is helpful, detailed instructions may overwhelm or confuse a forgetful older adult. Materials should be clear, concise, and easy to read, using layman's terms and possibly large print. However, this step alone does not ensure adherence, especially if the patient has difficulty processing or recalling information.

Make sure the patient understands the actions and side effects of each drug.

While understanding medications is important for safety and informed use, focusing solely on education may not address forgetfulness or promote adherence effectively. Understanding does not always translate to consistent medication-taking behavior, especially in patients with memory issues.

SUMMARY

To help promote adherence in a forgetful older adult with a multiple drug regimen, the most effective strategy is to simplify the regimen by clustering administration times. This reduces the cognitive burden and improves the chances of consistent medication use.

Correct Answer: The client reports that on a scale of 0 to 10, the current pain is a 3.

Detailed Explanation for the Correct Answer:

The client reports that on a scale of 0 to 10, the current pain is a 3.

This statement is the most objective and accurate form of pain documentation. It provides a measurable, client-reported value using a standard pain scale. Pain is a subjective experience, and the gold standard for assessing it is the client's own report. This option directly reflects that approach and offers a numerical value, which is essential for tracking pain over time.

Why the Other Options Are Incorrect:

The client is receiving sufficient relief from pain medication, stating no pain in either knee.

While this may seem reasonable, it lacks specificity. It does not include a numerical pain score, which is standard practice for documenting pain levels, and it uses vague language ("sufficient relief").

The client appears to have a low tolerance for pain and frequently reports intense pain.

This is subjective, judgmental, and inappropriate. It reflects the nurse’s opinion rather than objective data. The nurse should report what the client says, not interpret their pain tolerance.

The client appears comfortable and is resting adequately and appears to not be in acute distress.

Though it provides observations, this is still insufficient for pain documentation, as it does not include the client’s own report or a numerical scale. Comfort appearance does not replace asking the client directly about their pain.

Summary:

The most accurate and professional documentation of pain includes the client’s own report using a standardized pain scale. This allows for objective comparison over time and ensures that pain management can be effectively evaluated.