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. How should a healthcare professional monitor for infection in a patient with a central line?

• A. Check the central line dressing daily
• B. Monitor for signs of redness
• C. Check for abnormal breath sounds
• D. Monitor temperature

Correct answer: A

Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.

3. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

4. A nurse is caring for a client who has osteoarthritis. Which of the following findings should the nurse expect?

• A. Joint pain that improves with rest.
• B. Joint stiffness that improves with movement.
• C. Red, warm joints.
• D. Systemic inflammation.

Correct answer: A

Rationale: In osteoarthritis, joint pain that improves with rest is a common characteristic due to the relief obtained by reducing weight-bearing on the affected joint. Joint stiffness that improves with movement is more indicative of rheumatoid arthritis, not osteoarthritis. Red, warm joints are typically seen in inflammatory arthritis conditions like rheumatoid arthritis, while systemic inflammation is not a primary feature of osteoarthritis.

5. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

Similar Questions