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 has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?

• A. It is a condition in which one or more tumors, called gastrinomas, form in the pancreas or in the upper part of the small intestine (duodenum).
• B. It is critical to promptly report any findings of peptic ulcers to your health care provider.
• C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors.
• D. The average age at diagnosis is 50 years, and peptic ulcers may occur in unusual areas of the stomach or intestine.

Correct answer: B

Rationale: Prompt reporting of peptic ulcers is crucial in managing Zollinger-Ellison syndrome to prevent complications and guide treatment. While choices A, C, and D provide relevant information about the condition and its treatment, the most important aspect in the client's care is the prompt reporting of peptic ulcers. This is because untreated peptic ulcers in Zollinger-Ellison syndrome can lead to serious complications such as gastrointestinal bleeding or perforation. Therefore, ensuring timely communication with the healthcare provider is essential for effective management of the condition.

3. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A. Stay with the client and observe for airway obstruction
• B. Collect pillows and pad the side rails of the bed
• C. Place an oral airway in the mouth and suction
• D. Announce a cardiac arrest and assist with intubation

Correct answer: A

Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.

4. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.

5. 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.

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