Nursing Elites

1. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

2. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

• A. Client who has dysphagia
• B. Client who has AIDS
• C. Client who was vaccinated for pneumococcus and influenza 6 months ago
• D. Client who has a closed head injury and is receiving ventilation

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse documents this finding as:

• A. Tachypnea
• B. Hyperpyrexia
• C. Arrhythmia
• D. Tachycardia

Correct answer: D

Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.

4. Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?

• A. Bend at the waist and place arms under the client’s arms and lift
• B. Face the client, bend knees, and place hands on the client’s forearm and lift
• C. Spread the feet apart
• D. Tighten the pelvic muscles

Correct answer: C

Rationale: The correct answer is C: Spread the feet apart. When assisting a client to get up in a chair, it is crucial to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving. Choices A, B, and D are incorrect because bending at the waist, placing arms under the client's arms, tightening pelvic muscles, or placing hands on the client's forearm do not provide the necessary wide base support needed for stability and safety during the transfer process.

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

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