Author Question: Once a client is admitted and all the admission data are collected, the nurse is expected to develop ... (Read 51 times)

joblessjake · **on:** Jul 22, 2018

Once a client is admitted and all the admission data are collected, the nurse is expected to develop an initial plan for the client's care. By what point after admission should the nurse develop the plan?

A) No later than 48 hours
B) No later than 24 hours
C) No later than 72 hours
D) No later than 30 hours

Question 2

A nurse is determining the length of a nasogastric sump tube before inserting it inside a client. The nurse is placing the distal tip of the tube at the client's nose.

To which of the following places should the nurse measure the tube distance for proper placement? A) The jaw and then midway to the sternum
B) The mouth and then between the nipples
C) The midsternum and then to the umbilicus
D) The ear and then to the xiphoid process

kingdude89 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Feedback:
Once all admission data are collected, the nurse develops an initial plan for the client's care as soon as possible but no later than 24 hours following admission. The nurse cannot delay developing the initial plan for the client's care beyond 24 hours.

Answer to Question 2

D
Feedback:
The nurse obtains the length from the nose to earlobe to the xiphoid process and marks the tube appropriately. The first mark on the tube is made at the measured distance from the nose to the earlobe. It indicates the distance to the nasal pharynx, a location that places the tip at the back of the throat but above where the gag reflex is stimulated. The nurse need not measure the distance from jaw to sternum, from mouth to nipples, and from midsternum to umbilicus as these are incorrect procedures.