Nursing Elites

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

• A. Flush the tube with 10 mL of water after feeding
• B. Flush the tube with 30 mL of 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: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.

2. A nurse is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Client reports taking warfarin
• B. Client has a history of hypertension
• C. Client ate a light breakfast 2 hours prior
• D. Client reports a history of smoking 10 cigarettes a day

Correct answer: A

Rationale: The correct answer is A. Warfarin is an anticoagulant that increases the risk of bleeding during surgery. It is crucial for the provider to be informed about the client taking warfarin to adjust the treatment plan accordingly. Choices B, C, and D are not as critical to report for surgical planning. A history of hypertension (B) is important but may not require immediate intervention for surgery. Eating a light breakfast 2 hours prior (C) is a normal preoperative instruction. Smoking history (D) is relevant for overall health assessment but is not as urgent as the use of warfarin before surgery.

3. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Weight loss.
• B. Bradycardia.
• C. Peripheral edema.
• D. Dry cough.

Correct answer: C

Rationale: The correct answer is C: Peripheral edema. In right-sided heart failure, the heart struggles to pump blood efficiently, leading to fluid backup in the body. This fluid retention commonly manifests as peripheral edema, causing swelling in the legs, ankles, and feet. Choices A, B, and D are incorrect. Weight loss is not typically associated with right-sided heart failure; bradycardia (slow heart rate) is more commonly seen in conditions like hypothyroidism or athletes, not specifically in right-sided heart failure; and a dry cough is more commonly associated with conditions like pneumonia or bronchitis, not typically with right-sided heart failure.

5. A client who has a new diagnosis of tuberculosis should be placed in which type of room to prevent the spread of airborne pathogens?

• A. Administer isoniazid by mouth daily.
• B. Place the client in droplet isolation.
• C. Wear a surgical mask when transporting the client.
• D. Place the client in a negative pressure room.

Correct answer: D

Rationale: Clients diagnosed with tuberculosis should be placed in a negative pressure room to prevent the spread of airborne pathogens. Option A is incorrect because administering isoniazid is a treatment for tuberculosis, not a preventive measure related to infection control. Option B is incorrect as droplet isolation is used for diseases transmitted through respiratory droplets, not airborne pathogens like tuberculosis. Option C is incorrect as wearing a surgical mask is not sufficient to prevent the spread of tuberculosis in healthcare settings; placing the client in a negative pressure room is the most effective measure.

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