Nursing Elites

1. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in the microwave prior to administration

Correct answer: A

Rationale: The correct answer is to administer the feeding over 30 minutes. This slow administration helps prevent complications like nausea. Placing the child in a supine position after the feeding can increase the risk of aspiration, making choice B incorrect. Changing the feeding bag and tubing every 3 days is important for infection control and hygiene but is not directly related to the administration process, making choice C incorrect. Warming the formula in the microwave is not recommended as it can create hot spots that may burn the child's mouth or esophagus, so choice D is incorrect.

2. A healthcare professional is assessing a client who is receiving opioid analgesics. Which of the following findings should the professional report to the provider?

• A. Oxygen saturation of 94%
• B. Blood pressure of 110/70 mm Hg
• C. Respiratory rate of 12/min
• D. Heart rate of 88/min

Correct answer: C

Rationale: A respiratory rate of 12/min may indicate respiratory depression, a potential side effect of opioid analgesics. Respiratory depression can be a serious complication that requires immediate intervention. Monitoring the respiratory rate is crucial in clients receiving opioids to prevent adverse events. Oxygen saturation, blood pressure, and heart rate are important parameters to assess, but a low respiratory rate is a more critical finding that warrants immediate reporting to the healthcare provider.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?

• A. Encourage the client to take deep breaths.
• B. Place the client in a high-Fowler's position.
• C. Administer a bronchodilator.
• D. Administer oxygen at 6 L/min via face mask.

Correct answer: B

Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.

4. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?

• A. Perform an ECG every 12 hours
• B. Place the client in a supine position while resting
• C. Draw a troponin level every 4 hours
• D. Obtain a cardiac rehabilitation consultation

Correct answer: D

Rationale: After an acute myocardial infarction, it is important to involve the client in cardiac rehabilitation to help them recover and manage their condition effectively. Performing an ECG every 12 hours is not necessary unless there are specific indications for it. Placing the client in a supine position may not be ideal as it can increase venous return, potentially worsening cardiac workload. Drawing troponin levels every 4 hours is excessive and not recommended as troponin levels usually peak within 24-48 hours post-MI and then gradually decline.

5. A client with a new prescription for levothyroxine is receiving discharge teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication with food to prevent nausea.
• B. I will take this medication every morning before breakfast.
• C. I will stop taking this medication if I experience chest pain.
• D. I will take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken every morning before breakfast to enhance absorption and maintain consistent thyroid hormone levels. Option A is incorrect because levothyroxine should be taken on an empty stomach. Option C is incorrect because chest pain is not a common side effect of levothyroxine and stopping the medication abruptly can be harmful. Option D is incorrect because taking levothyroxine at bedtime may result in decreased absorption due to interactions with food and other medications.

Similar Questions