Nursing Elites

1. A healthcare provider is assessing a client who has anemia. Which of the following findings should the healthcare provider expect?

• A. Bradycardia.
• B. Pallor.
• C. Hypertension.
• D. Jaundice.

Correct answer: B

Rationale: Pallor is a common finding in clients with anemia due to decreased hemoglobin levels. Anemia leads to reduced oxygen-carrying capacity in the blood, resulting in pale skin and mucous membranes, which is known as pallor. Bradycardia, hypertension, and jaundice are typically not associated with anemia.

2. A client has a new prescription for digoxin, and a nurse is providing teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I will take my pulse before taking this medication.
• B. I will take this medication with an antacid.
• C. I will double the dose if I miss one.
• D. I will avoid eating bananas.

Correct answer: A

Rationale: The correct answer is A because taking the pulse before administering digoxin is crucial as the medication can cause bradycardia. Monitoring the pulse helps in identifying any signs of bradycardia, a common side effect of digoxin. Options B, C, and D are incorrect. Taking digoxin with an antacid may interfere with its absorption. Doubling the dose if a dose is missed can lead to overdose and adverse effects. Avoiding bananas is not specifically related to digoxin therapy.

3. A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?

• A. I should increase my intake of dairy products.
• B. I should decrease my intake of dairy products.
• C. I should increase my intake of high-fiber foods.
• D. I should decrease my intake of high-fat foods.

Correct answer: B

Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.

4. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

5. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

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