Nursing Elites

1. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Provide assistance to the bathroom
• B. Insert a straight catheter
• C. Increase fluids
• D. Perform a bladder scan

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

2. Which factor places a patient at the highest risk for infection?

• A. A healthy immune system
• B. Presence of chronic illness
• C. Being well-nourished
• D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

3. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?

• A. Confront the nurse about the behavior.
• B. Notify the hospital's safety committee.
• C. Document the observation without addressing it.
• D. Follow up with the nurse at a later time.

Correct answer: B

Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.

4. What are the key considerations when administering medication via a nasogastric (NG) tube?

• A. Checking tube placement before administration
• B. Administering medication in liquid form whenever possible
• C. Crushing tablets and mixing them with water if needed
• D. Flushing the NG tube with water before and after medication

Correct answer: A

Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.

5. A patient is receiving enteral feedings through a nasogastric (NG) tube. What is the most appropriate nursing intervention?

• A. Flush the NG tube with water before and after each feeding.
• B. Check the placement of the NG tube before each feeding.
• C. Administer medications through the NG tube every 4 hours.
• D. Increase the feeding rate if the patient is tolerating well.

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial as it ensures the tube is correctly positioned, reducing the risk of complications such as aspiration or improper delivery of feedings. Flushing the NG tube with water before and after each feeding can disrupt the feeding schedule and is not a standard procedure. Administering medications through the NG tube every 4 hours may not be necessary for all patients and should be based on specific medication requirements. Increasing the feeding rate without proper assessment and monitoring can lead to feeding intolerance or complications, making it an inappropriate intervention.

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