Nursing Elites

1. When administering medications through a nasogastric tube connected to low intermittent suction, which action should the nurse do first?

• A. Clamp the nasogastric tube
• B. Confirm placement of the tube
• C. Use a syringe to instill the medications
• D. Turn off the intermittent suction device

Correct answer: D

Rationale: When administering medications through a nasogastric tube connected to low intermittent suction, the nurse should first turn off the intermittent suction device. This step is crucial to prevent the medications from being immediately suctioned out before they can be absorbed. Clamping the nasogastric tube is not the initial action because it may cause pressure buildup and lead to complications. Confirming the placement of the tube is important but should not be the first step in this scenario. Using a syringe to instill the medications comes after ensuring the suction is turned off to enable proper administration and absorption of the medications.

2. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

• A. "I'm huge; I'm as big as a house."
• B. "I get straight A's in all my subjects."
• C. "My mother keeps trying to get me to eat."
• D. "My hair is beginning to fall out in clumps."

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

3. A client is being treated for anxiety and desires to be free from anxious feelings and despair. According to Maslow's hierarchy of needs, which level does this client need to meet?

• A. Physiological
• B. Safety
• C. Belonging
• D. Self-esteem

Correct answer: B

Rationale: According to Maslow's hierarchy of needs, safety needs come right after physiological needs. Safety needs include feelings of security and stability. When a client is treated for anxiety and seeks to be free from anxious feelings and despair, they are primarily aiming to meet their safety needs. By addressing anxiety and moving towards a sense of safety, the client can progress to addressing higher-level needs. Choices A, C, and D are incorrect in this scenario. Physiological needs (Choice A) refer to basic needs like food, water, and shelter. Belonging (Choice C) and self-esteem (Choice D) are higher-level needs in Maslow's hierarchy that come after safety needs. Therefore, the most appropriate level for the client in this case is safety.

4. When a client who has had a mastectomy sees her incision for the first time, she exclaims, 'I look horrible! Will it ever look better?' Which response would the nurse provide?

• A. 'You seem shocked by the way you look now.'
• B. 'Now that the tumor is gone, the area will heal quickly.'
• C. After it heals, others won't even know you had surgery.'
• D. 'You will feel better about it when the swelling subsides.'

Correct answer: A

Rationale: The correct response, 'You seem shocked by the way you look now,' acknowledges the client's feelings and provides an opportunity for the client to express emotions freely. This reflection of feelings may help promote eventual acceptance of body image changes. Choices B, C, and D provide false reassurance and negate the client's feelings. Saying that the area will heal quickly now that the tumor is gone dismisses the client's concerns. Similarly, stating that others won't know about the surgery or that the client will feel better once the swelling subsides does not address the client's current emotional state and may undermine trust in the nurse-client relationship.

5. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.

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