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 assessing a client who has pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Crackles in the lung bases
• C. Dependent edema
• D. Productive cough

Correct answer: C

Rationale: Dependent edema is a common finding in clients with pneumonia due to fluid retention and decreased mobility. Bradycardia (Choice A) is not typically associated with pneumonia. Crackles in the lung bases (Choice B) are more commonly heard in conditions like heart failure or pulmonary edema. A productive cough (Choice D) can be seen in pneumonia but is not as specific as dependent edema.

3. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor urine output
• B. Check blood pressure
• C. Monitor IV site
• D. Check respiratory rate

Correct answer: C

Rationale: When a patient is receiving IV potassium, it is crucial to monitor the IV site. Potassium can be irritating to the veins and may cause phlebitis or infiltration. Monitoring the IV site allows early detection of any potential complications. Checking urine output (Choice A) is important to assess kidney function but is not directly related to monitoring IV potassium. Blood pressure (Choice B) and respiratory rate (Choice D) are essential vital signs to monitor in general patient care but are not specific to monitoring IV potassium administration.

4. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Apply a dry dressing.
• B. Cleanse the wound with normal saline.
• C. Perform debridement as needed.
• D. Apply a hydrocolloid dressing.

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

5. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

• A. Encourage the client to take frequent rest periods.
• B. Withdraw TV privileges if the client does not attend group therapy.
• C. Place the client in seclusion during periods of anxiety.
• D. Encourage the client to spend time in the day room.

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

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