Nursing Elites

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

• A. Check the residual volume before administering the feeding
• B. Elevate the head of the bed to 30 degrees
• C. Flush the tube with 10 mL of sterile water
• D. Verify the client's tube placement

Correct answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.

2. A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 140/90 mm Hg
• B. Fasting blood glucose of 120 mg/dL
• C. Urinary output of 40 mL/hr
• D. Weight gain of 2.3 kg (5 lb) in 1 week

Correct answer: D

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.

3. A client with vision loss is being cared for by a nurse. Which of the following actions should the nurse take?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Touch the client gently to announce presence

Correct answer: A

Rationale: The correct action for the nurse to take is to keep objects in the client's room in the same place. This helps individuals with vision loss navigate their environment more easily by creating a familiar and consistent layout. Choice B, ensuring high-wattage lighting, may not be suitable for all clients with vision loss and can cause discomfort or glare. Approaching the client from the side (Choice C) can startle them and is not recommended. Touching the client (Choice D) without warning may cause anxiety or distress, so it's important to announce presence verbally.

4. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a bedtime snack if my blood sugar is below 200 mg/dL.
• B. I will eat more sugar-free candy to help control my blood sugar.
• C. I will check my blood sugar every morning before breakfast.
• D. I will avoid physical activity if my blood sugar is below 100 mg/dL.

Correct answer: C

Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.

5. A charge nurse is teaching a group of nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• A. Place a belt restraint on a school-age child who has seizures.
• B. Secure wrist restraints to the bed rails for an adolescent.
• C. Apply elbow immobilizers to an infant with a cleft lip injury.
• D. Keep the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct use of restraints is crucial to ensure patient safety. Keeping the side rails of a toddler's crib elevated is a safe practice as it prevents falls and provides a level of protection without directly restraining the child. Placing a belt restraint on a child with seizures (Choice A) is inappropriate as it may restrict movement and cause harm during a seizure. Securing wrist restraints to bed rails for an adolescent (Choice B) is not recommended as it can lead to injuries and compromise circulation. Applying elbow immobilizers to an infant with a cleft lip injury (Choice C) is also incorrect as it does not address the issue of restraint and is not a standard practice in this situation.

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