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. Upon admission, a 77-year-old female client presents with confusion, loss of appetite, nausea, vomiting, and headache, with a pulse rate of 43 beats per minute. Which question should the nurse prioritize asking the client or her family?

• A. Does the client have her own teeth or dentures?
• B. Does the client take aspirin, and if so, what is the dosage?
• C. Does the client take nitroglycerin?
• D. Does the client take digitalis?

Correct answer: D

Rationale: The correct answer is D. The client's symptoms suggest digitalis toxicity, a potentially life-threatening condition that requires immediate attention. Digitalis toxicity can present with symptoms such as anorexia, nausea, vomiting, headache, and bradycardia (low pulse rate). Given the client's presentation, it is crucial to assess for digitalis use as elderly individuals are more susceptible to this type of intoxication. Choices A, B, and C are important aspects to consider during the assessment, but in this scenario, the priority lies in identifying and addressing the potential digitalis toxicity due to the severity of symptoms and the need for prompt intervention.

3. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?

• A. I will take my medication only when I have chest pain.
• B. I will follow a heart-healthy diet and exercise regularly.
• C. I will avoid smoking and limit alcohol intake.
• D. I will contact my doctor if I experience chest pain or shortness of breath.

Correct answer: A

Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.

4. In a patient with diabetes mellitus, which of the following is a sign of hypoglycemia?

• A. Polydipsia.
• B. Polyuria.
• C. Sweating.
• D. Dry skin.

Correct answer: C

Rationale: Sweating is a common sign of hypoglycemia in diabetic patients. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can cause sweating as a response to the perceived danger. Polydipsia (excessive thirst) and polyuria (excessive urination) are actually more commonly associated with hyperglycemia, not hypoglycemia. Dry skin is not typically a sign of hypoglycemia.

5. A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client’s neck primarily because:

• A. It is unnecessary to use both hands
• B. Feeling dual pulsations may lead to an incorrect measurement
• C. Palpating both carotid pulses simultaneously could occlude the trachea
• D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

Correct answer: D

Rationale: The correct answer is D. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. Palpating both carotid pulses simultaneously could also interfere with the flow of blood to the brain, possibly causing dizziness and syncope. Choices A, B, and C are incorrect. It is necessary to use both hands to measure the carotid pulse accurately. Feeling dual pulsations does not lead to an incorrect measurement, and palpating both carotid pulses simultaneously does not occlude the trachea.

Similar Questions