Nursing Elites

1. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the tube with 30 mL of water every 4 hours.
• B. Position the client on the left side during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Check gastric residual every 2 hours.

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

2. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Hemoglobin 12 g/dL
• C. BUN 18 mg/dL
• D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

3. A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?

• A. Platelet count of 200,000/mm³
• B. Hemoglobin level of 15 g/dL
• C. Respiratory rate of 22/min
• D. Dark, tarry stools

Correct answer: D

Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.

4. How should a healthcare provider monitor a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT (activated partial thromboplastin time) when a patient is receiving heparin therapy. aPTT monitoring is essential for assessing the therapeutic effectiveness of heparin, ensuring the patient is within the desired therapeutic range to prevent both clotting and bleeding. Monitoring platelet count (Choice B) is important for assessing for heparin-induced thrombocytopenia but is not the primary monitoring parameter for heparin therapy. Monitoring sodium levels (Choice C) and calcium levels (Choice D) are not directly related to assessing the therapeutic effectiveness or potential side effects of heparin therapy.

5. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?

• A. Platelet count 150,000/mm³
• B. aPTT 30 seconds
• C. Sodium 140 mEq/L
• D. Serum creatinine 3.0 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.

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