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 nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

3. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

4. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?

• A. Reduce sodium intake to 4 grams per day
• B. Avoid foods high in potassium
• C. Take prescribed antihypertensive medications daily
• D. Limit fluid intake to 1 liter per day

Correct answer: C

Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.

5. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?

• A. Age and gender
• B. High-fat diet, smoking, alcohol consumption
• C. Ethnicity and race
• D. Exposure to radiation

Correct answer: B

Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.

Similar Questions