Nursing Elites

1. A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?

• A. Placing the tube in warm water
• B. Hyperextending the head while inserting the tube
• C. Removing the tube if any resistance to insertion is met
• D. Asking the client to swallow as the tube is being advanced

Correct answer: D

Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.

2. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

3. Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician’s orders to ensure that the prescribed flow is not greater than:

• A. 1 L/min
• B. 3 L/min
• C. 4 L/min
• D. 6 L/min

Correct answer: B

Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.

4. Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

• A. Place HIV-positive clients in strict isolation and limit visitors.
• B. Wear gloves when coming in contact with the blood or body fluids of any client.
• C. Conduct mandatory HIV testing of those who work with clients with AIDS.
• D. Freeze HIV blood specimens at -70°F to kill the virus.

Correct answer: B

Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.

5. A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?

• A. Avoid high carbohydrate foods.
• B. Decrease intake of fat-soluble vitamins.
• C. Decrease caloric intake.
• D. Restrict salt and fluid intake.

Correct answer: D

Rationale: The correct answer is to restrict salt and fluid intake. In clients with cirrhosis presenting with pedal edema and ascites, excessive fluid retention occurs, necessitating the restriction of salt and fluid to alleviate these symptoms. Choice A, avoiding high carbohydrate foods, is not the priority in this situation. Decreasing intake of fat-soluble vitamins (Choice B) is not specifically indicated for managing edema and ascites in cirrhosis. While maintaining an appropriate caloric intake is important, decreasing caloric intake (Choice C) is not the primary focus when addressing fluid retention in cirrhosis.

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