Nursing Elites

1. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

2. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 88/min
• D. Pallor of the affected extremity

Correct answer: D

Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?

• A. Encourage the client to take deep breaths.
• B. Place the client in a high-Fowler's position.
• C. Administer a bronchodilator.
• D. Administer oxygen at 6 L/min via face mask.

Correct answer: B

Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.

4. A client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

5. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Avoid eating spinach while taking this medication.
• B. Massage the injection site after administration.
• C. Administer the injection into the deltoid muscle.
• D. Inject the medication into the abdomen.

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

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