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 four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?

• A. A client who is postoperative following a laminectomy and is receiving IV PCA
• B. A client who has dysphagia and does not recognize his family
• C. A client who has COPD and is going home with oxygen
• D. A client who has colon cancer and will undergo a hemicolectomy

Correct answer: D

Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible.

3. A nurse is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the nurse that the client is experiencing Fluid Volume Deficit?

• A. Hct 53%
• B. Potassium 3.5
• C. Sodium 145
• D. HbA1c 5

Correct answer: A

Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit.

4. A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?

• A. Formula that remains in the bottle should be used for one more feeding.
• B. Formula should be changed to whole milk when the infant is 9 months old.
• C. If the infant is gaining weight too rapidly, dilute the formula.
• D. If the infant turns away after taking most of the feeding, stop the feeding.

Correct answer: D

Rationale: If the infant turns away after taking most of the feeding, it indicates they are full, and continuing to feed may lead to overfeeding.

5. A nurse is assessing the nutritional status of an infant who is 6 months old. The infant weighed 2.7 kg at birth. Which of the following indicate to the nurse that the infant is within expected range?

• A. 5.5 kg
• B. 6.4 kg
• C. 4.5 kg
• D. 3.6 kg

Correct answer: B

Rationale: An infant's weight should approximately double by 6 months. A weight of 6.4 kg indicates normal growth from a birth weight of 2.7 kg.

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