Nursing Elites

1. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

• A. Monitor intake and output every 8 hours.
• B. Flush the feeding tube every 4 hours.
• C. Measure the client's temperature every 24 hours.
• D. Change the feeding bag and tubing every 72 hours.

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

2. A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?

• A. Obtain a random blood glucose daily.
• B. Change the IV tubing every 72 hours.
• C. Apply a new dressing to the IV site every 24 hours.
• D. Weigh the client weekly.

Correct answer: A

Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events. Choices B, C, and D are incorrect because changing IV tubing every 72 hours, applying a new dressing to the IV site every 24 hours, and weighing the client weekly are not specific actions directly related to monitoring and managing the effects of TPN, particularly in relation to glucose levels.

3. A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage pursed-lip breathing.
• B. Administer oxygen at 6 L/min via nasal cannula.
• C. Place the client in a supine position.
• D. Restrict fluid intake to less than 1,500 mL/day.

Correct answer: A

Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.

4. A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-fiber foods.
• B. You should avoid foods containing lactose.
• C. You should decrease your intake of dairy products.
• D. You should increase your intake of dairy products.

Correct answer: C

Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.

5. What is a true statement about caring for a client with a nasogastric (NG) tube?

• A. The NG tube should be flushed with 30 mL of water every 4 hours.
• B. The client should be positioned in a supine position.
• C. The NG tube should be advanced 5 cm if resistance is met.
• D. The client's nasal mucosa should be inspected daily.

Correct answer: A

Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.

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