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 caring for a client with a major burn injury and is receiving TPN. Which of the following lab tests is the priority for the nurse to use to confirm the client is receiving adequate nutrition?

• A. Iron
• B. Magnesium
• C. Folic acid
• D. Prealbumin

Correct answer: D

Rationale: Prealbumin is a sensitive indicator of protein status and nutrition, making it a priority for assessing nutritional adequacy in clients receiving TPN.

3. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hr.
• B. Obtain the client’s electrolyte levels every 4 hr.
• C. Keep the client’s head elevated at 15* during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hr.

Correct answer: D

Rationale: Flushing the client's tube with 30 mL of water every 4 hours helps maintain tube patency and prevent blockages.

4. 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.

5. A nurse is teaching a group of clients about stress. Which of the following should the nurse include in the teaching?

• A. Protein requirements decrease in times of stress.
• B. Acute stress causes an increase in metabolism.
• C. Stress causes a positive nitrogen balance in the body.
• D. Glucose is broken down more slowly during times of stress.

Correct answer: B

Rationale: Acute stress causes an increase in metabolism, which is an important factor in stress management.

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