Nursing Elites

1. Enteral feedings may be appropriate for patients with:

• A. Acute cholecystitis
• B. Hepatic encephalopathy
• C. Ulcerative colitis in remission
• D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly used in patients with Crohn’s disease during acute exacerbations to provide adequate nutrition while resting the bowel. Acute cholecystitis, hepatic encephalopathy, and ulcerative colitis in remission wouldn't typically require enteral feedings as the primary nutritional support. Acute cholecystitis may necessitate fasting and intravenous fluids, hepatic encephalopathy may require dietary modifications but not enteral feedings, and patients with ulcerative colitis in remission usually have their nutritional needs met through a regular diet.

2. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

• A. Encouraging family discussion of feelings
• B. Accepting the family’s experience of anger
• C. Facilitating the use of spiritual practices identified by the family
• D. All of the above

Correct answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

3. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

• A. Encourage the client to drink liquids
• B. Perform active range of motion exercises
• C. Elevate the head of the bed to 45 degrees
• D. Provide a high-fiber diet to the client

Correct answer: B

Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.

4. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The position that best shows chest expansion as well as its movements is when the client is sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B (Prone) and Choice D (Supine) involve positions where the chest's movements and expansion are less visible and may not provide an accurate representation of respiratory function. Choice C (Sidelying) can also limit the visibility of chest expansion compared to the sitting position.

5. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

• A. Second intercostal space, right sternal border
• B. Erb’s point
• C. Second intercostal space, left sternal border
• D. Fourth intercostal space, left sternal border

Correct answer: A

Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.

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