Nursing Elites

1. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed to 15 degrees
• B. Check gastric residual volumes every 6 hours
• C. Monitor the pH of gastric aspirate
• D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

2. A nurse is caring for a client who has chronic kidney disease and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

• A. Decreased blood pressure
• B. Increased urine output
• C. Decreased heart rate
• D. Increased heart rate

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing fluid volume overload, the nurse should expect a decreased blood pressure. Fluid volume overload can lead to poor cardiac output, which in turn can cause a decrease in blood pressure. Choices B, C, and D are incorrect. Increased urine output is not expected in fluid volume overload; decreased heart rate is not typically associated with fluid volume overload; and an increased heart rate is more commonly seen in response to fluid overload to compensate for the decreased cardiac output.

3. A nurse is caring for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a well-lit area to reduce wandering.
• B. Use physical restraints to prevent wandering.
• C. Ensure that the client wears an identification bracelet at all times.
• D. Keep the client's bed in the lowest position.

Correct answer: C

Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.

4. What is the best way to monitor fluid balance in a patient with kidney disease?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Check urine output

Correct answer: A

Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.

5. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.5 mg/dL
• C. Potassium 5.2 mEq/L
• D. Magnesium 2.0 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

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