Nursing Elites

1. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with the removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.

2. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

• A. Ask another nurse to witness the disposal of the new patch
• B. Dispose of the patch in a sharps container
• C. Send the patch back to the pharmacy
• D. Document the refusal and remove the patch

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

3. A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Lie down after meals to reduce discomfort.
• B. Limit fluid intake to 1 liter per day.
• C. Avoid eating spicy foods.
• D. Eat three large meals each day.

Correct answer: C

Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.

4. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?

• A. Carrots
• B. Whole grains
• C. Lean beef
• D. Bananas

Correct answer: C

Rationale: The correct answer is 'Lean beef.' Lean beef is a good source of protein, which is essential for a balanced diet. While carrots and bananas are healthy food choices, they are not specifically recommended for clients with hypertension. Whole grains are a better alternative to refined grains for individuals with hypertension, but lean beef is a more suitable recommendation due to its protein content.

5. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take a tablet every 5 minutes for pain relief, up to three doses.
• B. Take this medication with a glass of water.
• C. Chew the tablet for faster absorption.
• D. Store the tablets in a refrigerator.

Correct answer: A

Rationale: The correct answer is A: 'Take a tablet every 5 minutes for pain relief, up to three doses.' Nitroglycerin sublingual tablets are used to relieve chest pain or to prevent chest pain before activities known to cause angina. The tablets should be taken every 5 minutes for pain relief, up to three doses, as prescribed. Choice B is incorrect because nitroglycerin sublingual tablets should be placed under the tongue until they dissolve, not taken with water. Choice C is incorrect because nitroglycerin sublingual tablets should not be chewed but placed under the tongue for absorption. Choice D is incorrect because nitroglycerin tablets should be stored in their original container at room temperature away from light and moisture.

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