Nursing Elites

1. A client has a new prescription for a potassium-sparing diuretic. Which of the following foods should the nurse recommend?

• A. Bananas
• B. Oranges
• C. Spinach
• D. Apples

Correct answer: D

Rationale: Clients on potassium-sparing diuretics need to avoid high-potassium foods to prevent hyperkalemia. Apples are a low-potassium fruit, making them a suitable recommendation for clients on this type of diuretic. Bananas, oranges, and spinach are high-potassium foods that should be avoided by clients taking potassium-sparing diuretics to prevent complications such as hyperkalemia.

2. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

3. A healthcare professional is preparing to administer a subcutaneous injection of insulin. Which of the following actions should the professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, inserting the needle at a 90-degree angle is appropriate. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Using a 1-inch needle is common for subcutaneous injections to reach the subcutaneous fat layer adequately. Tuberculin syringes are typically used for intradermal injections, not subcutaneous injections. Aspirating before injecting is not necessary for subcutaneous injections as it is primarily used for intramuscular injections to ensure the needle is not in a blood vessel.

4. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

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