Nursing Elites

1. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Nausea
• B. Decreased heart rate
• C. Weight gain
• D. Fever

Correct answer: A

Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.

2. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

3. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

4. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

• A. Verbal self-report
• B. Pain scale
• C. Behavioral indicators
• D. Observing facial expressions

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

5. A client is found on the floor experiencing a seizure. What is the nurse's priority action?

• A. Apply oxygen
• B. Place the client on their side
• C. Administer an anticonvulsant
• D. Notify the provider

Correct answer: B

Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.

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