Nursing Elites

1. A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?

• A. Increased bowel sounds
• B. Nausea
• C. Elevated blood pressure
• D. Fever

Correct answer: B

Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.

2. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the IV line
• C. Apply a cold compress
• D. Elevate the limb

Correct answer: B

Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.

3. When teaching about safety risks for adolescents, what should the nurse emphasize?

• A. Adolescents have a decreased risk of injury
• B. Peer pressure can lead to risky behaviors
• C. Increased responsibility reduces risks
• D. Adolescents are less likely to engage in substance abuse

Correct answer: B

Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.

4. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

5. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?

• A. Administer prescribed antibiotics
• B. Initiate seizure precautions
• C. Identify the client's needs
• D. Place the client in isolation

Correct answer: C

Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.

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