Nursing Elites

1. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes. The nurse should assess tube placement in this way before taking any other action to ensure the tube is still in the correct position and prevent potential complications. Choice A is incorrect because further assessment is needed due to the risk of tube displacement. Choice B is incorrect as stopping the feeding and involving the family is premature without confirming tube placement. Choice D is incorrect as injecting air and auscultating for gurgling is not the recommended method to confirm tube placement.

2. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

• A. Raise the bed to a comfortable working level.
• B. Bend the client's knee.
• C. Move the knee toward the chest as far as it will go.
• D. Cradle the client's heel.

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

3. Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?

• A. Using a water-soluble lubricant.
• B. Administering 100% oxygen before and after suctioning.
• C. Ensuring that the suction catheter is open during insertion.
• D. Assisting the client to assume a semi-Fowler's position during suctioning.

Correct answer: B

Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.

4. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

5. The client has a chest tube. What is the most important action for the nurse to take?

• A. Ensure the chest tube remains unclamped at all times.
• B. Empty the chest tube every 2 hours.
• C. Keep the drainage system below the level of the chest.
• D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

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