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 client who has a prescription for insulin glargine is talking to a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will mix this insulin with my regular insulin before injecting it.
• B. I will store this insulin in the refrigerator after opening it.
• C. I will take this insulin twice a day.
• D. I will inject this insulin when my blood glucose is above 200 mg/dL.

Correct answer: B

Rationale: The correct answer is B because insulin glargine should be stored in the refrigerator after opening to maintain its potency. Choice A is incorrect as insulin glargine should not be mixed with other insulins. Choice C is incorrect because insulin glargine is typically taken once a day. Choice D is incorrect because insulin glargine is usually taken regardless of blood glucose levels.

3. A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit your fluid intake to 3 liters per day.
• B. Increase your fluid intake to 5 liters per day.
• C. Avoid drinking more than 1 liter of fluid per day.
• D. You can drink as much fluid as you want during meals.

Correct answer: C

Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.

4. A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 118/76 mm Hg
• B. Heart rate of 88/min
• C. Urinary output of 30 mL/hr
• D. Hematocrit 42%

Correct answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

5. How should a healthcare professional monitor a patient for infection post-surgery?

• A. Monitor the surgical site
• B. Monitor for fever
• C. Check blood pressure
• D. Check for redness

Correct answer: A

Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.

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