Nursing Elites

1. A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?

• A. Formula that remains in the bottle should be used for one more feeding.
• B. Formula should be changed to whole milk when the infant is 9 months old.
• C. If the infant is gaining weight too rapidly, dilute the formula.
• D. If the infant turns away after taking most of the feeding, stop the feeding.

Correct answer: D

Rationale: If the infant turns away after taking most of the feeding, it indicates they are full, and continuing to feed may lead to overfeeding.

2. A nurse is preparing to remove a client’s clogged NG tube prior to re-inserting a new tube. Which of the following actions should the nurse take first?

• A. Assist the client to blow her nose.
• B. Ask the client to take a deep breath and hold it.
• C. Pinch the proximal end of the tube.
• D. Disconnect the tube from suction source.

Correct answer: D

Rationale: Disconnecting the tube from the suction source is the first step in safely removing a clogged NG tube.

3. A nurse is preparing to administer a gavage feeding via nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?

• A. Stabilize the tube with tape to the newborn’s forehead.
• B. Remove supplemental oxygen during the feeding.
• C. Measure the stomach aspirate prior to the feeding.
• D. Place the newborn on her left side for 30 min after the feeding.

Correct answer: C

Rationale: Measuring the stomach aspirate prior to the feeding is essential to ensure proper placement and function of the NG tube.

4. A nurse is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?

• A. BUN 8 mg/dL
• B. Hgb 15 g/dL
• C. Creatinine 0.8 mg/dL
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: A BUN level of 8 mg/dL is indicative of fluid volume excess, which is common in clients with heart failure.

5. A nurse is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the nurse that the client is experiencing Fluid Volume Deficit?

• A. Hct 53%
• B. Potassium 3.5
• C. Sodium 145
• D. HbA1c 5

Correct answer: A

Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit.

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