CPNRE Nursing Care and Interventions 2

Question 1

A client has an NGT and is ordered tube feeding. Before starting, which action confirms correct tube placement?

Accepted Answer

Check pH of aspirate and verify tube length marking at the nose

Answer

Inject air and listen with a stethoscope

Answer

Auscultate for bowel sounds in all four quadrants

Answer

Verify by feeling resistance when injecting water

Question 2

A client has been ordered a glycerin suppository. Which action should be taken before insertion?

Accepted Answer

Warm to body temperature and lubricate with water-soluble lubricant

Answer

Refrigerate immediately before use to firm it

Answer

Crush and dilute in water for administration

Answer

Administer with a glass of warm water for faster effect

Question 3

When inserting a urinary catheter for a male client, the catheter meets resistance at the external urethral sphincter. What is the most appropriate action?

Accepted Answer

Ask the client to take a deep breath and relax, then gently advance

Answer

Apply firm pressure to advance past the resistance

Answer

Remove and attempt a smaller gauge catheter

Answer

Call the physician since male catheterization is beyond scope

Question 4

A client is prescribed subcutaneous heparin 5000 units. Which administration technique is most appropriate?

Accepted Answer

Inject into the abdomen 5 cm from the umbilicus, do not aspirate, do not massage

Answer

Aspirate before injection and massage vigorously after

Answer

Inject into the deltoid muscle and apply pressure

Answer

Aspirate before each injection

Question 5

When changing a wound dressing, which finding requires immediate reporting?

Accepted Answer

A wound base that becomes deep red, firm, with surrounding pale indented tissue and foul odor

Answer

Serosanguinous drainage consistent with previous documentation

Answer

Wound edges that appear approximated and pink

Answer

Wound size that has slightly decreased from previous measurement

Question 6

When performing a 12-lead ECG, which electrode placement is correct for lead V4?

Accepted Answer

Fifth intercostal space at the midclavicular line

Answer

Fourth intercostal space, right sternal border

Answer

Fourth intercostal space, left sternal border

Answer

Anterior axillary line, same level as V4