Nursing Elites

1. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?

• A. An x-ray shows the end of the tube above the pylorus.
• B. The tube is aspirated and contains clear gastric fluid.
• C. The tube is flushed with sterile water without resistance.
• D. The client does not cough or choke during tube insertion.

Correct answer: B

Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.

2. A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?

• A. Daily needs and concerns
• B. The overview of cardiac rehabilitation
• C. Medication and diet guidelines
• D. Activity and rest guidelines

Correct answer: A

Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.

3. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

4. A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?

• A. Drink 8 oz of water with each dose of medication.
• B. Use medications that have a short half-life.
• C. Take each dose right after breastfeeding.
• D. Pump breast milk and discard it prior to feeding the newborn.

Correct answer: C

Rationale: Taking medications immediately after breastfeeding helps minimize the amount of medication that enters breast milk. By doing so, there is a longer interval between the medication intake and the next breastfeeding session, reducing the concentration of the medication in breast milk. Options A and B are incorrect as drinking water with medication or using medications with a short half-life do not directly minimize the entry of medication into breast milk. Option D is unnecessary and wasteful as pumping and discarding breast milk before feeding is not as effective as timing medication intake with breastfeeding to reduce medication transfer into breast milk.

5. A client recovering from lung cancer is advised to resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

• A. Washing dishes
• B. Mowing the lawn
• C. Carrying heavy groceries
• D. Gardening

Correct answer: A

Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.

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