Nursing Elites

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

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

2. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

3. A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer?

• A. Calcium gluconate
• B. Sodium bicarbonate
• C. Potassium chloride
• D. Sodium phosphate

Correct answer: A

Rationale: Calcium gluconate is the correct answer because it is administered to treat hypocalcemia, a common complication post-thyroidectomy. After a thyroidectomy, there is a risk of damaging the parathyroid glands, which can lead to a decrease in calcium levels. Administering calcium gluconate helps to raise calcium levels. Sodium bicarbonate (Choice B) is not typically indicated for immediate postoperative care following a subtotal thyroidectomy. Potassium chloride (Choice C) is not directly related to the common complications of this specific surgery. Sodium phosphate (Choice D) is not typically used to address immediate postoperative issues post-thyroidectomy.

4. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?

• A. Prothrombin time (PT)
• B. International Normalized Ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.

5. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase oxytocin infusion.
• B. Decrease oxytocin infusion.
• C. Maintain oxytocin infusion.
• D. Discontinue oxytocin infusion.

Correct answer: D

Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.

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