Nursing Elites

1. During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?

• A. Stop advancing the tube and allow the client to rest
• B. Remove the tube and try again after a few minutes
• C. Continue inserting the tube while the client sips water
• D. Withdraw the tube slightly and pause before continuing

Correct answer: D

Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.

2. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

• A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
• B. Instruct the UAP not to wake the client under any circumstances during the night.
• C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
• D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Correct answer: A

Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.

3. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

• A. The client reports pain at the IV site
• B. The client’s heart rate is irregular
• C. The client has swelling at the IV site
• D. The client’s blood pressure is elevated

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

4. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

• A. Removing the empty food tray from a client with a urinary catheter.
• B. Washing and combing the hair of a client with a fractured leg in traction.
• C. Administering oral medications to a cooperative client with a wound infection.
• D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

5. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

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