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 client is receiving discharge teaching for a new prescription of digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will stop taking this medication if my heart rate is below 80/min.
• B. I should take my pulse before taking this medication.
• C. I should stop taking this medication if my pulse is above 100/min.
• D. I will take this medication with an antacid.

Correct answer: B

Rationale: The correct answer is B. Clients taking digoxin should check their pulse before each dose to ensure it is within the appropriate range. Option A is incorrect because stopping the medication based solely on a heart rate below 80/min is not recommended. Option C is incorrect as having a pulse above 100/min doesn't necessarily indicate a need to stop digoxin. Option D is incorrect because digoxin should not be taken with an antacid as it can interfere with its absorption.

3. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

• A. Hypnosis focuses on biofeedback as a relaxation technique
• B. Hypnosis promotes increased control of pain perception during contractions
• C. Hypnosis uses therapeutic touch to reduce anxiety during labor
• D. Hypnosis provides instruction to minimize pain

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

4. What is the most important nursing action when a patient has a central line?

• A. Monitor for infection
• B. Monitor the central line dressing
• C. Monitor for redness
• D. Monitor for swelling

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

5. A healthcare professional is reviewing the laboratory results of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the professional report to the provider?

• A. Blood glucose level of 130 mg/dL
• B. Serum sodium level of 140 mEq/L
• C. Serum potassium level of 3.2 mEq/L
• D. Platelet count of 250,000/mm³

Correct answer: C

Rationale: A serum potassium level of 3.2 mEq/L indicates hypokalemia, a complication that should be reported in clients receiving TPN. Hypokalemia can lead to serious cardiac and neuromuscular complications. The other options are within normal ranges and do not indicate immediate concerns for a client receiving TPN. A blood glucose level of 130 mg/dL, serum sodium level of 140 mEq/L, and platelet count of 250,000/mm³ are all considered normal values and do not require immediate intervention.

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