the lpn is checking for residual before administering enteral feeding through a peg tube which of these steps is incorrect

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

A. The LPN elevates the head of the bed by at least 30 degrees.
B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
C. The LPN should discard the residual before administering the tube feeding.
D. The residual pH level is tested to ensure appropriate placement.

Correct answer: C

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

2. The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?

A. "Yes, I promise you I will be your nurse during my shift tomorrow."?
B. "You will need to speak to my supervisor about this request."?
C. "While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request."?
D. "Because of confidentiality, I cannot discuss tomorrow's assignments with you."?

Correct answer: D

Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments. Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation. Choice D respects confidentiality and is the most professional response in this scenario.

3. A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?

A. Telling the health care provider that the client would probably want to die in peace
B. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken
C. Telling the health care provider that all of the nurses on the unit agree with this plan
D. Telling the health care provider that 'slow codes' are not acceptable

Correct answer: D

Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.

4. Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control.
B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

5. When placing a Foley catheter in a female client, what is the correct order of steps?

A. E, A, F, B, C, G, D
B. A, E, B, F, G, D, C
C. A, E, F, B, C, G, D
D. E, A, F, B, C, G, D

Correct answer: D

Rationale: The correct order for placing a Foley catheter in a female client is as follows: E. Place the client in a supine position with flexed knees, A. Prepare the sterile field, F. Place lubricant on the catheter, B. Separate labia with the non-dominant hand, C. Clean the urinary meatus using cleansing solutions and forceps, G. Place the catheter in the meatus with the dominant (sterile) hand, and D. Inflate the catheter balloon. This sequence ensures proper hygiene, patient comfort, and reduces the risk of infection. Incorrect sequences could compromise sterility, cause discomfort, and increase the risk of infection. Therefore, the correct answer is E, A, F, B, C, G, D.