Nursing Elites

1. Before administration of blood and blood products, the nurse should first:

• A. Check with another R.N the client’s name, Identification number, ABO and RH type.
• B. Explain the procedure to the client
• C. Assess baseline vital signs of the client
• D. Check for the BT order

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hours.
• B. Obtain the client’s electrolyte levels every 4 hours.
• C. Keep the client’s head elevated at 15° during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hours.

Correct answer: D

Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

3. Which food provides a 1-ounce serving of grains for a preschool child?

• A. 1 cup of ready-to-eat cereal flakes
• B. 1⁄2 slice of whole wheat bread
• C. 1⁄2 of a 6-inch flour tortilla
• D. 1 cup of cooked rice

Correct answer: A

Rationale: The correct answer is A: 1 cup of ready-to-eat cereal flakes. For a preschool child, 1 cup of ready-to-eat cereal flakes provides a 1-ounce serving of grains, meeting the requirement. Choice B, 1⁄2 slice of whole wheat bread, is not the correct answer as it does not constitute a 1-ounce serving of grains. Similarly, choice C, 1⁄2 of a 6-inch flour tortilla, does not offer a 1-ounce serving of grains. Choice D, 1 cup of cooked rice, also does not provide a 1-ounce serving of grains for a preschool child, making it an incorrect choice.

4. A client with pre-dialysis end-stage kidney disease is being taught about diet. Which of the following instructions should the nurse include?

• A. Increase intake of dietary phosphorus.
• B. Eliminate foods high in protein from your diet.
• C. Reduce intake of foods high in potassium.
• D. Increase intake of sodium-containing foods.

Correct answer: C

Rationale: In pre-dialysis end-stage kidney disease, reducing intake of foods high in potassium is crucial as impaired kidney function can lead to potassium buildup in the blood, which can be dangerous. High potassium levels can cause irregular heartbeats and even cardiac arrest. Therefore, advising the client to reduce potassium-rich foods is essential to prevent complications. Choices A, B, and D are incorrect. Increasing dietary phosphorus, eliminating foods high in protein, or increasing sodium-containing foods are not appropriate recommendations for a client with pre-dialysis end-stage kidney disease as they can exacerbate the condition.

5. To raise HDL levels, what is Mrs. Smith advised to do?

• A. quit smoking
• B. increase dietary sodium
• C. take iron supplements
• D. avoid dairy products

Correct answer: A

Rationale: The correct answer is A: quit smoking. Smoking lowers HDL levels, so quitting smoking is crucial to raising HDL levels. Increasing dietary sodium (choice B) is not linked to raising HDL levels and can have negative effects on cardiovascular health. Taking iron supplements (choice C) is not directly related to increasing HDL levels. Avoiding dairy products (choice D) is not necessary to raise HDL levels; in fact, some dairy products like low-fat options can be part of a heart-healthy diet.

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