Nursing Elites

1. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

2. A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. Blood pressure 130/80 mm Hg
• C. Weight gain of 2.2 kg (5 lb) in 1 week
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.

3. A healthcare professional is reviewing laboratory results for a client who has cirrhosis. Which of the following findings should the professional report to the provider?

• A. Albumin 3.5 g/dL
• B. Bilirubin 1.0 mg/dL
• C. INR 3.0
• D. Ammonia 80 mcg/dL

Correct answer: C

Rationale: An INR of 3.0 is elevated, indicating impaired blood clotting function, which poses a significant risk of bleeding in clients with cirrhosis. This finding should be promptly reported to the provider for further evaluation and management. Choice A (Albumin 3.5 g/dL) is within the normal range and indicates adequate liver synthetic function, so it does not require immediate reporting. Choice B (Bilirubin 1.0 mg/dL) is also within the normal range and typically seen in clients without significant liver dysfunction, so it does not need urgent attention. Choice D (Ammonia 80 mcg/dL) is elevated, but it is not the priority finding in cirrhosis; elevated ammonia levels are associated with hepatic encephalopathy rather than increased bleeding risk.

4. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

5. A nurse is assessing a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Tachycardia
• B. Dry mouth
• C. Diaphoresis
• D. Increased appetite

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common sign of hypoglycemia due to the activation of the sympathetic nervous system. Tachycardia (choice A) is more commonly associated with hyperglycemia. Dry mouth (choice B) is not a typical finding in hypoglycemia but may be seen in hyperglycemia. Increased appetite (choice D) is not a typical sign of hypoglycemia and is more commonly associated with hyperglycemia.

Similar Questions