Nursing Elites

1. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

• A. Flush the tube with 100 mL of water
• B. Verify tube placement
• C. Elevate the head of the bed
• D. Measure the residual gastric volume

Correct answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

2. A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?

• A. I will take naps during the day to help me sleep at night
• B. I should drink caffeine to help me stay awake during the day
• C. I should reduce my fluid intake 2 hours before bedtime
• D. I should exercise right before bed to tire myself out

Correct answer: C

Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.

3. A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?

• A. Increased breath sounds
• B. Flushed skin
• C. Nasal flaring
• D. Decreased respiratory rate

Correct answer: B

Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.

4. A client has a new prescription for a cane. What instruction should the nurse include?

• A. Hold the cane on the weaker side
• B. Ensure the cane has a rubber tip
• C. Keep the cane on the dominant side
• D. Use the cane only on stairs

Correct answer: B

Rationale: The correct instruction the nurse should include is to ensure the cane has a rubber tip. This is important as it prevents slipping and ensures safety while walking. Choice A is incorrect because the cane should be held on the stronger side to provide better support. Choice C is incorrect as the cane should be used on the stronger, not the dominant, side for stability. Choice D is incorrect because a cane can be used for support in various situations, not just on stairs.

5. A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased fiber intake
• B. Decreased physical activity
• C. Frequent urge suppression
• D. Adequate sleep

Correct answer: B

Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.

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