Nursing Elites

1. After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.

2. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

• A. You should increase the fiber in your diet.
• B. You should increase the calories in your diet.
• C. You should decrease the dairy products in your diet.
• D. You should decrease the amount of vitamin D in your diet.

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

3. A healthcare professional is preparing to administer an enteral feeding via an established NG tube. Which option is not part of the sequence the healthcare professional should follow to initiate the feeding?

• A. Verify tube placement
• B. Check the residual feeding contents
• C. Administer the feeding
• D. Limit protein intake

Correct answer: D

Rationale: The correct sequence for initiating enteral feeding includes verifying tube placement to ensure safety, checking the residual feeding contents to prevent complications, and then administering the feeding. Limiting protein intake is not a step in the sequence for initiating enteral feeding. Protein intake may be adjusted based on the patient's specific nutritional needs, but it is not a part of the immediate sequence for initiating the feeding. Therefore, option D is the correct answer. Options A, B, and C are essential steps to ensure the safe and effective administration of enteral feeding.

4. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A. Institute seizure precautions
• B. Monitor neurologic status every hour
• C. Place in respiratory/secretion precautions
• D. Cefotaxime IV 50 mg/kg/day divided q6h

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

5. The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?

• A. I will limit my intake of high-sodium foods.
• B. I will take my medications as prescribed by my healthcare provider.
• C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
• D. I will limit my intake of high-fat foods.

Correct answer: A

Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.

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