Nursing Elites

1. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?

• A. “I should keep feeding my son whole milk until he is 3 years old.”
• B. “It’s okay for me to give my son a cup of apple juice with each meal.”
• C. “I’ll give my son about 2 tablespoons of each food at mealtimes.”
• D. “My son loves popcorn, and I know it is better for him than sweets.”

Correct answer: C

Rationale: The correct answer is C. Offering a variety of foods in small portions is appropriate for a 2-year-old toddler as it helps provide balanced nutrition and allows the child to explore different tastes and textures. Choice A is incorrect because whole milk is recommended up to 2 years old, not until 3 years old. Choice B is incorrect as excessive juice intake can lead to excessive sugar consumption and is not recommended. Choice D is incorrect as popcorn may pose a choking hazard for toddlers and is not a suitable alternative to sweets.

2. The healthcare professional is preparing to administer a medication through a nasogastric (NG) tube. Which action should the healthcare professional take to ensure proper administration?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: Flushing the NG tube with water before and after medication administration is essential to ensure the tube is patent and prevent clogging. This action helps in clearing the tube and ensures that the medication is delivered properly. Administering medication with food (Choice B) may not be appropriate for all medications and can interfere with their absorption. Verifying tube placement by aspirating stomach contents (Choice C) is important but does not directly relate to ensuring proper medication administration. Diluting the medication with normal saline (Choice D) is not a standard practice for administering medications through an NG tube.

3. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

• A. Notify the manufacturer
• B. Disconnect the machine, and measure the blood pressure manually every 15 min
• C. Adjust the machine settings again
• D. Ignore the extra readings

Correct answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

4. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

• A. Administer cardiac compressions
• B. Attach the AED pads to the client
• C. Check for a pulse
• D. Perform rescue breaths

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

5. Prior to a client being transported for a chest x-ray, what should a healthcare professional do first?

• A. Identify the client using two identifiers
• B. Confirm the client's fasting status
• C. Check the client's allergies to contrast media
• D. Explain the procedure to the client

Correct answer: A

Rationale: Identifying the client using two identifiers is the crucial first step to ensure correct patient identification before any procedure. This process helps prevent errors and ensures that the right procedure is performed on the right patient. Confirming the client's identity is the top priority before addressing other aspects such as fasting status, allergies, or explaining the procedure. While confirming fasting status and checking for allergies are important, they are secondary to confirming the client's identity. Explaining the procedure to the client is also essential but should occur after ensuring proper identification.

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