Nursing Elites

1. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

• A. I can give you information about respite care if you are interested.
• B. You should consider taking a sleeping pill before bed each night.
• C. It must be difficult taking care of someone who is terminally ill.
• D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

2. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

• A. Avoid using deodorant until the incision heals.
• B. Perform arm exercises 24 hours after surgery.
• C. Wear tight-fitting clothing to support the incision.
• D. Perform arm exercises 2 days after surgery.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

3. What is the correct method of administering insulin to a patient with diabetes?

• A. Administer subcutaneously
• B. Administer intramuscularly
• C. Administer intravenously
• D. Administer orally

Correct answer: A

Rationale: The correct method of administering insulin to a patient with diabetes is to administer it subcutaneously. Insulin is typically injected into the fatty tissue just below the skin, allowing for a slow and consistent absorption into the bloodstream. Administering insulin intramuscularly (Choice B) is not recommended as it can lead to unpredictable absorption rates and potential complications. Administering insulin intravenously (Choice C) is only done in specific medical settings and not for routine diabetes management. Administering insulin orally (Choice D) is ineffective as the stomach acid would break down the insulin before it can be absorbed.

4. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

5. A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will need to check my blood glucose level once a week.
• B. I will limit my carbohydrate intake to 50 grams per day.
• C. I should avoid eating foods high in protein.
• D. I should eat a snack if my blood glucose level is below 200 mg/dL.

Correct answer: D

Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.

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