Nursing Elites

1. When assisting a client with bilateral casts on her hands with feeding, what action should the nurse take?

• A. Sit at the bedside when feeding the client
• B. Provide pureed foods
• C. Ensure feedings are provided at room temperature
• D. Offer the client a drink of fluid after every bite

Correct answer: A

Rationale: When assisting a client with bilateral casts on her hands with feeding, the nurse should sit at the bedside. This action is crucial to provide the client with the nurse's full attention during the feeding process. Sitting at the bedside helps avoid appearing rushed and ensures a safe and comfortable environment for the client. Choices B, C, and D are incorrect because while they may be relevant in other situations, the priority when assisting a client with bilateral casts on her hands is to ensure proper attention and a comfortable setting during feeding.

2. A client has a prescription for a soft diet. Which of the following foods should the nurse offer?

• A. Fresh apples
• B. Mashed potatoes
• C. Raw carrots
• D. Nuts

Correct answer: B

Rationale: When a client is on a soft diet, it is important to offer foods that are easy to chew and swallow. Mashed potatoes are a suitable choice for a soft diet as they are soft in texture and easy to digest. Fresh apples, raw carrots, and nuts are harder and may not be appropriate for a soft diet. Fresh apples and raw carrots require more chewing, and nuts are hard and crunchy, which can be difficult for someone on a soft diet to consume. Therefore, mashed potatoes are the correct option for a client on a soft diet.

3. A client has a new prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

• A. Pickles
• B. Canned soup
• C. Fresh fruits
• D. Smoked salmon

Correct answer: C

Rationale: Fresh fruits are naturally low in sodium, making them a suitable choice for a low-sodium diet. They provide essential nutrients and are a healthy option for individuals who need to limit their sodium intake. Pickles (Choice A) and canned soup (Choice B) are typically high in sodium and should be avoided in a low-sodium diet. Smoked salmon (Choice D) is also usually high in sodium due to the smoking process, so it is not a recommended choice for a low-sodium diet.

4. When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?

• A. Complete a fall-risk assessment
• B. Place a fall-risk identification bracelet on the client
• C. Provide the client with nonskid footwear
• D. Set the bed to the lowest position

Correct answer: A

Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.

5. 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.

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