Nursing Elites

1. A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?

• A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
• B. Discard the residual volume properly and record it as output on the client’s fluid balance record
• C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
• D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

Correct answer: A

Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.

2. After a lumbar puncture, into which position does the nurse assist the client?

• A. Flat
• B. Semi-Fowler
• C. Side-lying with the head of the bed elevated
• D. Sitting up in a recliner with the feet elevated

Correct answer: A

Rationale: After a lumbar puncture, the client should be positioned flat. This position helps prevent post-procedure spinal headaches and cerebrospinal fluid leakage. Keeping the client flat for up to 12 hours is crucial in minimizing these risks. Choices B, C, and D are incorrect because elevating the head of the bed or sitting up can increase the risk of complications by altering the pressure in the spinal canal, potentially leading to headaches and fluid leakage.

3. A nurse reviews laboratory results for a client with glomerulonephritis. The client’s glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)

• A. Excessive GFR
• B. Reduced GFR
• C. Fluid retention and risks for hypertension
• D. Pulmonary edema

Correct answer: B

Rationale: A GFR of 40 mL/min indicates a reduced glomerular filtration rate. In a healthy adult, the normal GFR ranges between 100 and 120 mL/min. A GFR of 40 mL/min signifies a significant reduction, leading to fluid retention and risks for hypertension and pulmonary edema due to excess vascular fluid. Choices A, C, and D are incorrect. Choice A is incorrect as a GFR of 40 mL/min is not excessive but rather reduced. Choices C and D do not directly address the interpretation of GFR but instead describe potential consequences of a reduced GFR.

4. Which of the following is a characteristic symptom of multiple sclerosis (MS)?

• A. Muscle atrophy.
• B. Severe pain.
• C. Vision problems.
• D. Hearing loss.

Correct answer: C

Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.

5. After checking the client’s gag reflex following an esophagogastroduodenoscopy (EGD), which action should the nurse take?

• A. Taking the client’s vital signs
• B. Giving the client a drink of water
• C. Monitoring the client for a sore throat
• D. Being alert to complaints of heartburn

Correct answer: A

Rationale: After an esophagogastroduodenoscopy (EGD), the nurse's priority is to assess the client's airway by checking the gag reflex. Once this assessment is done, the next step is to take the client's vital signs to monitor for any signs of complications such as bleeding or changes in respiratory status. Giving the client water immediately after the procedure may not be appropriate, as the client may still have a compromised gag reflex and is at risk for aspiration. Monitoring for a sore throat is important but not the immediate priority post-procedure. Being alert to complaints of heartburn is relevant for assessing the client's symptoms but is not the priority immediately after checking the gag reflex.

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