Nursing Elites

1. A nurse is assessing a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings requires immediate intervention?

• A. Aspirating 100 mL of gastric residual
• B. Gastric pH of 4
• C. Auscultating crackles in the lung bases
• D. Checking residual every 6 hours

Correct answer: C

Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.

2. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administration of acetaminophen
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

3. What is the priority nursing assessment for a patient with chronic kidney disease?

• A. Monitor serum creatinine
• B. Monitor blood pressure
• C. Monitor urine output
• D. Monitor potassium levels

Correct answer: A

Rationale: The correct answer is to monitor serum creatinine. In patients with chronic kidney disease, monitoring serum creatinine is crucial as it reflects kidney function. This assessment helps healthcare providers in evaluating the progression of the disease and adjusting treatment plans accordingly. Monitoring blood pressure (choice B) is essential in managing chronic kidney disease, but monitoring serum creatinine takes precedence. Monitoring urine output (choice C) and potassium levels (choice D) are also important aspects of managing chronic kidney disease, but they are not the priority assessment compared to monitoring serum creatinine.

4. A nurse is reviewing the medical records of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, leading to decreased blood clotting ability. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can lead to bleeding in thrombocytopenic clients. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is important for immunocompromised clients to prevent exposure to pathogens but is not specifically related to thrombocytopenia. Avoiding serving raw vegetables (Choice D) is a precaution to reduce the risk of infection in immunocompromised clients but does not directly address the complications of thrombocytopenia.

5. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the nurse demonstrating?

• A. Quality improvement
• B. Patient safety
• C. Evidence-based practice
• D. Informatics

Correct answer: A

Rationale: The correct answer is A: Quality improvement. Completing an incident report after a client fall aligns with the quality improvement competency of QSEN, as it involves identifying a system issue (fall incident) that needs to be addressed to enhance the quality of care. Choice B, patient safety, focuses more on preventing harm to patients rather than the systematic improvement process. Choice C, evidence-based practice, pertains to integrating research evidence with clinical expertise and patient values in decision-making, which is not directly related to incident reporting. Choice D, informatics, involves using technology and data to support decision-making and improve patient care, which is not the primary focus when completing an incident report.

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