Nursing Elites

1. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

• A. Increased blood pressure
• B. Increased heart rate
• C. Loss of pulse in the extremity
• D. Decreased urine output

Correct answer: C

Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.

2. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

• A. Hold the tube feeding and notify the provider
• B. Administer the tube feeding as scheduled
• C. Irrigate the tube with diet cola soda
• D. Apply intermittent suction to the feeding tube

Correct answer: A

Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.

3. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

• A. Assessing the client's level of consciousness
• B. Monitoring the client's oxygen saturation
• C. Checking the client's gag reflex before eating or drinking
• D. Monitoring the client's intake and output

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

4. A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?

• A. Yogurt
• B. Fresh vegetables
• C. Nuts
• D. Dried beans

Correct answer: A

Rationale: Corrected Rationale: Yogurt contains all essential amino acids, making it a complete protein. Choice B, fresh vegetables, are incomplete proteins. Choice C, nuts, are also incomplete proteins. Choice D, dried beans, are incomplete proteins. Therefore, the correct answer is yogurt because it is a source of complete protein.

5. Which statement best describes the effects of immobility in children?

• A. Immobility prevents the progression of language and fine motor development
• B. Immobility in children has similar physical effects to those found in adults
• C. Children are more susceptible to the effects of immobility than adults are
• D. Children are likely to have prolonged immobility with subsequent complications

Correct answer: B

Rationale: The correct answer is B. Immobility in children indeed has physical effects similar to those found in adults. However, it can also significantly impact their development and growth. Choice A is incorrect because immobility does not solely prevent language and fine motor development but affects various aspects. Choice C is incorrect as susceptibility to the effects of immobility may vary between children and adults depending on individual factors. Choice D is incorrect as not all children are likely to have prolonged immobility with subsequent complications.

Similar Questions