Nursing Elites

1. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

• A. Keep the catheter clamped when not in use
• B. Have the client perform the Valsalva maneuver while the catheter is removed
• C. Use a non-coring needle to access the catheter
• D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.

2. A client is receiving a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Rub the injection site after administration.
• B. Pinch the skin while administering the injection.
• C. Aspirate before administering the medication.
• D. Avoid taking aspirin while using this medication.

Correct answer: D

Rationale: The correct answer is D: 'Avoid taking aspirin while using this medication.' Enoxaparin is an anticoagulant medication, and taking aspirin concurrently can increase the risk of bleeding. Choices A, B, and C are incorrect. A nurse should not instruct the client to rub the injection site after administration as it may cause irritation. Pinching the skin while administering the injection is not recommended for enoxaparin injections. Aspirating before administering the medication is also unnecessary as enoxaparin is administered subcutaneously, not intramuscularly.

3. A nurse is providing teaching to a client who has a new prescription for atorvastatin. Which of the following instructions should the nurse include?

• A. Avoid drinking grapefruit juice while taking this medication.
• B. Take this medication with food to prevent stomach upset.
• C. You should take this medication at bedtime.
• D. You should take this medication on an empty stomach.

Correct answer: A

Rationale: The correct answer is A: 'Avoid drinking grapefruit juice while taking this medication.' Grapefruit juice can increase the risk of toxicity when taken with atorvastatin. Choice B is incorrect because atorvastatin should be taken without regard to meals. Choice C is incorrect because atorvastatin can be taken at any time of the day. Choice D is incorrect because atorvastatin does not need to be taken on an empty stomach.

4. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following dietary recommendations should the nurse make?

• A. Increase your intake of high-fiber foods.
• B. Avoid foods that are high in fat.
• C. Increase your intake of dairy products.
• D. Drink carbonated beverages to help with bloating.

Correct answer: B

Rationale: The correct answer is B: "Avoid foods that are high in fat." Clients with IBS should avoid foods high in fat as they can exacerbate symptoms such as abdominal pain, bloating, and diarrhea. High-fiber foods, choice A, can sometimes worsen symptoms in individuals with IBS. Increasing intake of dairy products, choice C, may also worsen symptoms for some individuals with IBS, especially if they are lactose intolerant. Drinking carbonated beverages, choice D, can contribute to bloating and gas, making symptoms worse for individuals with IBS.

5. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the tube with 30 mL of water every 4 hours.
• B. Position the client on the left side during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Check gastric residual every 2 hours.

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

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