Nursing Elites

1. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings?

• A. Aspirate for gastric secretions with a syringe.
• B. Begin feeding slowly to prevent cramping.
• C. Get an X-ray of the tip of the tube within 24 hours.
• D. Clamp off the tube until the feedings begin.

Correct answer: A

Rationale: Immediately after inserting an NG tube for enteral feedings, aspirate for gastric secretions to confirm proper placement.

2. The nurse provides discharge instructions to a patient with hepatitis B. Which of the following statements, if made by the patient, would indicate the need for further instruction?

• A. I can never donate blood.
• B. I can never have unprotected sex.
• C. I cannot share needles.
• D. I should avoid drugs and alcohol.

Correct answer: D

Rationale: The correct answer is D. This patient statement indicates a need for further teaching. The patient should be instructed that, in order to avoid complications, alcohol should be avoided for six months to one year. Illicit drugs and toxic chemicals should also be avoided. Acetaminophen may be taken only when necessary and not beyond the recommended dosage. Choices A, B, and C are correct statements regarding precautions to prevent the spread of hepatitis B and do not indicate a need for further instruction.

3. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

• A. Inspect skin around the T tube daily for irritation.
• B. Irrigate the T tube every 4 hours to maintain patency.
• C. Maintain the client in a supine position while the T tube is in place.
• D. Keep the T tube clamped except during mealtimes.

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

4. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

• A. Restrict fluids
• B. Encourage ambulation
• C. Increase sodium in the diet
• D. Give antacids as prescribed

Correct answer: A

Rationale: Restricting fluids is necessary to decrease the excessive accumulation of serous fluid in the peritoneal cavity for a patient with ascites due to cirrhosis.

5. The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

• A. Development of laryngeal cancer
• B. Irritation of the esophagus
• C. Esophageal scar tissue formation
• D. Aspiration of gastric contents

Correct answer: D

Rationale: Aspiration of gastric contents can lead to a chronic cough in clients with GERD.

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