Nursing Elites

1. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

2. When assisting a client with bilateral casts on her hands with feeding, what action should the nurse take?

• A. Sit at the bedside when feeding the client
• B. Provide pureed foods
• C. Ensure feedings are provided at room temperature
• D. Offer the client a drink of fluid after every bite

Correct answer: A

Rationale: When assisting a client with bilateral casts on her hands with feeding, the nurse should sit at the bedside. This action is crucial to provide the client with the nurse's full attention during the feeding process. Sitting at the bedside helps avoid appearing rushed and ensures a safe and comfortable environment for the client. Choices B, C, and D are incorrect because while they may be relevant in other situations, the priority when assisting a client with bilateral casts on her hands is to ensure proper attention and a comfortable setting during feeding.

3. When teaching a client with a new diagnosis of hypertension about medication adherence, which statement should the nurse include?

• A. You can stop taking your medication once your blood pressure is normal.
• B. You should take your medication at the same time every day.
• C. You can double your dose if you miss a dose.
• D. You should take your medication with a high-fat meal.

Correct answer: B

Rationale: The correct answer is B: 'You should take your medication at the same time every day.' Taking medication consistently at the same time daily is crucial for maintaining steady blood levels and effectively managing hypertension. It helps ensure that the medication works optimally and provides the best control of blood pressure throughout the day. Choice A is incorrect because stopping medication once blood pressure is normal can lead to a relapse or worsening of hypertension. Choice C is incorrect as doubling the dose without healthcare provider guidance can be dangerous. Choice D is incorrect as taking medication with a high-fat meal can affect its absorption and efficacy.

4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

5. A client with a new diagnosis of pancreatitis is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

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

Correct answer: B

Rationale: The correct statement the nurse should include in teaching a client with pancreatitis is to decrease the intake of high-fat foods. This dietary modification is crucial in managing symptoms and preventing exacerbations of pancreatitis. High-fat foods can put a strain on the pancreas, potentially leading to further complications. Choice A is incorrect because increasing intake of high-fat foods can worsen pancreatitis. Choice C is unrelated to pancreatitis management, as lactose intolerance is not directly linked to pancreatitis. Choice D is also incorrect, as increasing dairy product intake may not be suitable for all individuals with pancreatitis due to the fat content in many dairy products.

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