Nursing Elites

1. A client is experiencing a seizure. Which of the following interventions should the nurse implement?

• A. Place a tongue depressor in the client's mouth
• B. Loosen tight clothing around the client
• C. Restrain the client's arms and legs
• D. Administer 100% oxygen via non-rebreather mask

Correct answer: B

Rationale: During a seizure, it is essential to loosen tight clothing around the client to prevent injury and promote adequate ventilation. Placing any objects, like a tongue depressor, in the client's mouth can lead to airway obstruction or injury. Restraining the client's arms and legs can exacerbate the situation by increasing muscle rigidity and potentially causing injury. Administering oxygen via a non-rebreather mask is not typically indicated during a seizure unless respiratory distress is present.

2. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 10 mL of water after feeding
• B. Flush the tube with 30 mL of water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.

3. A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.

4. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

5. A client is receiving discharge teaching for a new prescription of digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will stop taking this medication if my heart rate is below 80/min.
• B. I should take my pulse before taking this medication.
• C. I should stop taking this medication if my pulse is above 100/min.
• D. I will take this medication with an antacid.

Correct answer: B

Rationale: The correct answer is B. Clients taking digoxin should check their pulse before each dose to ensure it is within the appropriate range. Option A is incorrect because stopping the medication based solely on a heart rate below 80/min is not recommended. Option C is incorrect as having a pulse above 100/min doesn't necessarily indicate a need to stop digoxin. Option D is incorrect because digoxin should not be taken with an antacid as it can interfere with its absorption.

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