Nursing Elites

1. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hr.
• B. Obtain the client’s electrolyte levels every 4 hr.
• C. Keep the client’s head elevated at 15* during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hr.

Correct answer: D

Rationale: Flushing the client's tube with 30 mL of water every 4 hours helps maintain tube patency and prevent blockages.

2. A nurse is caring for a client who is receiving a continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: Checking for gastric residual can help identify the cause of cramping and abdominal distention during enteral feedings.

3. A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

• A. Encourage the client to participate in developing a system of rewards.
• B. Arrange for someone to remain with the client for 30 min after meals
• C. Offer the client a selection of beverages at each meal.
• D. Inform the client that a weight gain of 2.3 kg per week is expected.

Correct answer: A

Rationale: Encouraging the client to participate in developing a system of rewards can help motivate and engage them in their treatment plan.

4. A nurse is caring for a client who has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

• A. Replace the bag and tubing every 24 hr
• B. Flush the tubing with 10 mL water every 6 hr
• C. Admin the feeding by gravity drip
• D. Heat the formula prior to infusion

Correct answer: B

Rationale: Flushing the tubing with 10 mL of water every 6 hours helps prevent clogging when using high-viscosity formulas.

5. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?

• A. 2 hr glucose tolerance test level 150 mg/dL
• B. Fasting blood glucose 70 mg
• C. Glycosylated hemoglobin 5%
• D. Casual blood glucose 90 mg/dL

Correct answer: A

Rationale: A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance.

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