Nursing Elites

1. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

2. A nurse is providing teaching to a client who has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent gastrointestinal upset.
• B. Take this medication in the morning to prevent insomnia.
• C. You may experience weight gain while taking this medication.
• D. You should avoid eating foods that contain iodine.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to take levothyroxine in the morning is important to prevent insomnia, a common side effect of this medication. Choice A is incorrect as levothyroxine should be taken on an empty stomach. Choice C is inaccurate because weight loss, not weight gain, is a potential side effect of levothyroxine. Choice D is not necessary as clients do not need to avoid foods containing iodine while taking levothyroxine.

3. A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?

• A. I will need to increase my intake of leafy green vegetables.
• B. I will avoid drinking grapefruit juice while taking warfarin.
• C. I will have my INR checked regularly.
• D. I will take my medication at the same time each day.

Correct answer: C

Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.

4. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

5. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

• A. Avoid using deodorant until the incision heals.
• B. Perform arm exercises 24 hours after surgery.
• C. Wear tight-fitting clothing to support the incision.
• D. Perform arm exercises 2 days after surgery.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

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