Nursing Elites

1. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?

• A. Elevate the head of the bed to 30-45 degrees.
• B. Check residual volumes every 4 hours.
• C. Verify tube placement every shift.
• D. Flush the tube with water every 4 hours.

Correct answer: A

Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.

2. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

• A. “I am struggling to accept that my parents are aging and need so much help.”
• B. “It’s been so stressful for me to think about having intimate relationships.”
• C. “I know I should volunteer my time for a good cause, but maybe I’m just selfish.”
• D. “I love my grandchildren, but my child expects me to relive my parenting days.”

Correct answer: A

Rationale: The correct answer is A. The statement about struggling with aging parents indicates a significant stressor that could impact overall well-being and warrants further assessment. This statement reveals a potential source of emotional distress and adjustment difficulties for the client, as aging parents needing help can be a complex issue involving feelings of loss, role reversal, and increased responsibilities. Choices B, C, and D, although important, do not signify as immediate a need for further assessment compared to the challenges related to aging parents. Choice B focuses on intimate relationships, which is a common concern but may not be as urgent as dealing with aging parents. Choice C reflects feelings of selfishness but does not indicate an immediate need for further assessment. Choice D involves expectations from the client's child but does not highlight a critical issue that could impact the client's well-being as directly as struggling with aging parents.

3. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

4. During an integumentary assessment for a group of clients, a healthcare professional notes various skin findings. Which of the following findings should the professional recognize as requiring immediate intervention?

• A. Pallor
• B. Cyanosis
• C. Jaundice
• D. Erythema

Correct answer: B

Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.

5. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

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