A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

Prepare to initiate antibiotic therapy.

Obtain a prescription for a chest x-ray.

Position the client on their side.

Suction the client's orotracheal airway.

Answer and Explanation

The Correct Answer is C

A. Prepare to initiate antibiotic therapy: Antibiotics may be necessary if aspiration pneumonia develops, but this is not an immediate nursing action. Medication initiation requires provider evaluation and a prescription, making this a delayed intervention.

B. Obtain a prescription for a chest x-ray: A chest x-ray may be ordered to confirm aspiration, but requesting this is not the nurse’s next priority. Immediate nursing interventions to protect the airway and prevent further complications must occur first.

C. Position the client on their side: Placing the client on their side helps prevent further aspiration and promotes drainage of secretions or feeding material from the airway. This is the safest immediate response after stopping the feeding.

D. Suction the client's orotracheal airway: Suctioning is appropriate if the client has visible secretions, is coughing ineffectively, or shows respiratory distress. However, the priority immediate action is to position the client to reduce aspiration risk before suctioning if needed.

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Correct Answer is "{\"xRanges\":[33.882846916299556,42.693419603524234],\"yRanges\":[29.535864978902953,37.9746835443038]}"

Explanation

A. Throat/Pharynx area: The gag reflex must be checked before giving fluids. Anesthetics used during bronchoscopy suppress the gag and cough reflex, which places the client at high risk of aspiration. Assessing the throat for return of reflexes ensures safe swallowing.

B. Head/Brain area: Assessing the brain is not necessary prior to resuming oral intake after bronchoscopy. Neurological function is important overall, but it does not determine whether the swallowing reflex has returned and if the client can safely manage oral fluids.

C. Mouth/Lips: Examining the lips or oral cavity may reveal dryness, bleeding, or trauma, but it does not determine readiness for fluids. The risk of aspiration persists unless gag reflex recovery is confirmed.

D. Chest/Lungs area: Assessing lung sounds is important for evaluating complications such as bronchospasm or pneumothorax, but this does not confirm readiness for oral intake. Aspiration risk remains the main concern until gag reflex recovery is established.

A. "Place guns in a locked glass cabinet." B. "Keep ammunition and guns in separate, locked locations." C. "Remove ammunition from the firearm and place it on a table before cleaning." D. "Plan to have the firearm inspected by a gunsmith every 5 years."

Correct Answer is B

Explanation

A. "Place guns in a locked glass cabinet.": A glass cabinet, even if locked, does not provide adequate security because glass can be broken easily. This storage method increases the risk of children or unauthorized individuals accessing the firearm.

B. "Keep ammunition and guns in separate, locked locations.": Storing firearms and ammunition separately and in locked containers minimizes the risk of accidental shootings by ensuring that even if one is accessed, the other remains secured, thereby preventing immediate use.

C. "Remove ammunition from the firearm and place it on a table before cleaning.": Although removing ammunition is necessary before cleaning, leaving it out in the open still poses a risk. Safe practices require storing ammunition in a secure, locked area rather than accessible.

D. "Plan to have the firearm inspected by a gunsmith every 5 years.": While firearm inspections may be useful for maintenance, they do not directly reduce the risk of injury in the home. Safety measures focus more on secure storage and limiting access to firearms and ammunition.

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A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[33.882846916299556,42.693419603524234],\"yRanges\":[29.535864978902953,37.9746835443038]}"

Explanation

A school nurse is teaching a group of guardians about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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