Nursing Elites

1. A client receiving intermittent enteral feedings is being cared for by a nurse. Which action should the nurse take to reduce the risk of aspiration?

• A. Administer the feeding over 60 minutes.
• B. Position the client in a supine position during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Flush the feeding tube with 60 mL of water before each feeding.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration during enteral feedings is to elevate the head of the bed to 45 degrees. This position helps prevent the reflux of feeding into the lungs. Administering the feeding over 60 minutes (Choice A) does not directly reduce the risk of aspiration. Positioning the client in a supine position (Choice B) increases the risk of aspiration as it promotes reflux. Flushing the feeding tube with water (Choice D) is important for tube patency but does not directly reduce the risk of aspiration.

2. A client is 1 day postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent respiratory complications?

• A. Instruct the client to avoid deep breathing exercises
• B. Encourage the use of an incentive spirometer
• C. Assist the client with ambulation every 2 hours
• D. Apply sequential compression devices (SCDs)

Correct answer: B

Rationale: Encouraging the use of an incentive spirometer is crucial for preventing respiratory complications postoperatively, such as atelectasis. Instructing the client to avoid deep breathing exercises (choice A) is incorrect as deep breathing exercises help prevent respiratory complications. Assisting with ambulation every 2 hours (choice C) is important for preventing other postoperative complications but not specifically respiratory ones. Applying sequential compression devices (SCDs) (choice D) is beneficial for preventing deep vein thrombosis but not directly related to respiratory complications.

3. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate 60/min.
• B. Blood pressure 110/70 mm Hg.
• C. Serum potassium 4 mEq/L.
• D. Blood pressure 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

4. A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?

• A. This medication will decrease my potassium levels.
• B. I should eat a banana every day to increase my potassium intake.
• C. I will stop taking this medication if I experience a cough.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking furosemide should avoid alcohol because it can lead to dehydration and potential interactions with the medication. Choices A and B are incorrect because furosemide is a diuretic that can actually lower potassium levels, so the client should not expect an increase in potassium levels or solely rely on bananas for potassium intake. Choice C is incorrect because a cough is not a common side effect of furosemide and should not be a reason to stop taking the medication.

5. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide?

• A. Personal blogs about managing diabetes medications
• B. Food exchange lists for meal planning from the American Diabetes Association
• C. Diabetes medication information from the Physicians' Desk Reference
• D. Food label recommendations from the Institute of Medicine

Correct answer: B

Rationale: The correct answer is B. Food exchange lists from the American Diabetes Association are a reliable resource for meal planning in diabetes. They provide structured guidance on appropriate food choices and portion sizes. Choice A, personal blogs, may not always offer accurate and evidence-based information. Choice C, diabetes medication information from the Physicians' Desk Reference, is not directly related to meal planning. Choice D, food label recommendations from the Institute of Medicine, while important for understanding nutritional content, may not provide the structured meal planning guidance needed for a client with type 2 diabetes mellitus.

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