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 developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

• A. Place the client upright on a donut-shaped cushion.
• B. Teach the client to shift his weight every 15 minutes while sitting.
• C. Turn and reposition the client every 3 hours.
• D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

3. A nurse is providing dietary teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid eating leafy green vegetables while taking this medication.
• B. I will increase my intake of calcium-rich foods.
• C. I will avoid foods high in vitamin K while taking this medication.
• D. I will take this medication at bedtime to avoid dizziness.

Correct answer: C

Rationale: Clients taking warfarin should avoid foods high in vitamin K, as it can interfere with the effectiveness of the medication.

4. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Furosemide can cause low potassium levels, and clients should be advised to rise slowly to prevent dizziness.

5. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

• A. Limit sodium intake to no more than 1,500 mg per day.
• B. Exercise for at least 150 minutes each week.
• C. Avoid all dairy products.
• D. Limit intake of all carbohydrates.

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

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