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. When should a healthcare provider suction a client's tracheostomy?

• A. When the client is hypotensive
• B. When the client is irritable
• C. When the client is flushed
• D. When the client is bradycardic

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

3. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

4. What are the key nursing interventions for a patient undergoing dialysis?

• A. Monitor fluid balance and administer heparin
• B. Monitor blood pressure and prevent clot formation
• C. Administer medications and monitor blood chemistry
• D. Provide dietary education and encourage protein intake

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

5. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

• A. Position the drainage bag below the bladder
• B. Wipe the drainage port after emptying
• C. Insert the catheter using sterile technique
• D. Avoid cleansing the urinary meatus

Correct answer: B

Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.

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