Nursing Elites

1. A nurse is caring for a client who is receiving a continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: Checking for gastric residual can help identify the cause of cramping and abdominal distention during enteral feedings.

2. A nurse is evaluating the meal choices of a client who has major depressive disorder and a prescription of Phenelzine. Which of the following selections should the nurse identify as appropriate?

• A. Cheddar cheese
• B. Smoked salmon
• C. Strawberry yogurt
• D. Pepperoni pizza

Correct answer: C

Rationale: Strawberry yogurt is appropriate as it does not contain high levels of tyramine, which can interact negatively with Phenelzine.

3. A nurse is planning care for a client who reports increasing difficulty swallowing food. Which of the following interventions should the nurse plan to take?

• A. Turn on the client’s television during meals.
• B. Place the client into a semi-reclining position for meals.
• C. Encourage the client to rest prior to mealtimes.
• D. Encourage the client to use a straw when drinking liquids.

Correct answer: C

Rationale: Encouraging the client to rest prior to mealtimes can help reduce fatigue and improve the ability to swallow.

4. A nurse is preparing to remove a client’s clogged NG tube prior to re-inserting a new tube. Which of the following actions should the nurse take first?

• A. Assist the client to blow her nose.
• B. Ask the client to take a deep breath and hold it.
• C. Pinch the proximal end of the tube.
• D. Disconnect the tube from suction source.

Correct answer: D

Rationale: Disconnecting the tube from the suction source is the first step in safely removing a clogged NG tube.

5. A nurse is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the nurse that the client is experiencing Fluid Volume Deficit?

• A. Hct 53%
• B. Potassium 3.5
• C. Sodium 145
• D. HbA1c 5

Correct answer: A

Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit.

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