Nursing Elites

1. A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of sterile water before each feeding
• B. Administer the feeding using a large-bore syringe
• C. Keep the head of the bed elevated to 15 degrees
• D. Replace the feeding bag every 24 hours

Correct answer: A

Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.

2. A nurse is planning care for a client who is receiving hemodialysis. What action should the nurse include in the plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action that the nurse should include in the plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is important to prevent complications such as infection or excessive bleeding. Withholding all medications until after dialysis (Choice A) is not necessary unless specific medications need to be avoided due to the dialysis process. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not a standard practice unless there is a specific clinical indication.

3. A client is immediately postoperative following a hip arthroplasty. Which of the following positions should the nurse maintain for the client?

• A. Supine with legs extended
• B. Semi-Fowler's position with legs bent
• C. Lateral position with an abduction pillow between the legs
• D. Prone with legs elevated

Correct answer: C

Rationale: The correct position for a client immediately postoperative following a hip arthroplasty is the lateral position with an abduction pillow between the legs. This position helps prevent dislocation of the hip prosthesis and maintains proper alignment of the hip joint. Supine position with legs extended (Choice A) may put stress on the hip joint, Semi-Fowler's position with legs bent (Choice B) may not provide adequate support and alignment, and prone position with legs elevated (Choice D) is not recommended after hip arthroplasty as it can compromise the surgical site and increase the risk of complications.

4. How should a healthcare professional educate a patient on the use of an incentive spirometer?

• A. Instruct the patient to take deep breaths
• B. Instruct the patient to cough forcefully
• C. Instruct the patient to blow into the spirometer
• D. Instruct the patient to use the spirometer every hour

Correct answer: D

Rationale: Instructing the patient to use the spirometer every hour is crucial for optimal lung expansion and to prevent postoperative pulmonary complications. This regular use helps to keep the lungs clear and maintain their capacity. Choices A, B, and C are incorrect because deep breathing, forceful coughing, and blowing into the spirometer do not specifically address the proper use of the incentive spirometer, which is essential for postoperative respiratory recovery.

5. A nurse is reviewing the medical record of a client who has acute kidney injury. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 15 mg/dL
• B. Urine output of 45 mL/hr
• C. Serum creatinine 3.5 mg/dL
• D. Calcium 9 mg/dL

Correct answer: C

Rationale: The correct answer is C, 'Serum creatinine 3.5 mg/dL.' An elevated serum creatinine level indicates worsening kidney function and impaired renal clearance, which should be reported to the provider promptly. Choice A, 'Blood urea nitrogen (BUN) 15 mg/dL,' is within the normal range (7-20 mg/dL) and does not indicate acute kidney injury. Choice B, 'Urine output of 45 mL/hr,' is a low urine output but does not directly reflect kidney function decline. Choice D, 'Calcium 9 mg/dL,' is within the normal calcium range (8.5-10.5 mg/dL) and is not specifically indicative of acute kidney injury.

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