Nursing Elites

1. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?

• A. Administer an antiemetic
• B. Irrigate the NG tube with sterile water
• C. Increase the suction setting
• D. Replace the NG tube

Correct answer: B

Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.

2. A client reports difficulty having a bowel movement. What is the most appropriate intervention?

• A. Administer a laxative to relieve constipation
• B. Encourage the client to increase fiber intake
• C. Advise the client to rest in bed to avoid straining
• D. Encourage the client to exercise to stimulate bowel movement

Correct answer: B

Rationale: The correct answer is to encourage the client to increase fiber intake. Fiber helps promote regular bowel movements by adding bulk to the stool, making it easier to pass. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependency and may not address the underlying cause of constipation. Advising the client to rest in bed (Choice C) may worsen constipation as physical activity helps stimulate bowel movements. Encouraging the client to exercise (Choice D) is beneficial, but increasing fiber intake is more directly related to improving bowel movements in this scenario.

3. A client undergoing surgery is being taught about the use of a patient-controlled analgesia (PCA) pump by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will ask my spouse to push the button when I am sleeping
• B. I will use the PCA pump to keep me comfortable during the night
• C. I will ask the nurse to increase the dosage if I still feel pain
• D. I will press the button for medication as soon as I feel pain

Correct answer: D

Rationale: The correct answer is D because clients should press the button on the PCA pump when they feel pain to receive controlled doses of medication. Option A is incorrect as the client should be the one to self-administer the medication through the PCA pump. Option B is incorrect as the primary purpose of the PCA pump is to manage pain, not to keep the client comfortable. Option C is incorrect because the client should not adjust the dosage themselves; instead, they should communicate any pain concerns to the healthcare provider.

4. A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?

• A. Place a bed exit alarm
• B. Use restraints to prevent the client from getting out of bed
• C. Ask the client's family to stay at the bedside
• D. Encourage frequent ambulation with assistance

Correct answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

5. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

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