Nursing Elites

1. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

• A. Discarded properly and recorded as output on the client’s intake and output record.
• B. Poured into the nasogastric tube through a syringe with the plunger removed.
• C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
• D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

2. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

• A. Concave, midline umbilicus
• B. Pulsation between the umbilicus and pubis
• C. Bowel sound frequency of 15 sounds per minute
• D. Absence of a bruit

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

3. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer?

• A. Pain that is relieved by food intake
• B. Pain that radiated down the right arm
• C. N/V
• D. Weight loss

Correct answer: A

Rationale: Pain that is relieved by food intake is the most frequent symptom of duodenal ulcers because the food neutralizes the stomach acid.

4. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

• A. 1/16”
• B. 1/4″
• C. 1/2”
• D. 1”

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

5. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure because of which change that is associated with the liver failure?

• A. Hypoalbuminemia
• B. Increased capillary permeability
• C. Abnormal peripheral vasodilation
• D. Excess rennin release from the kidneys

Correct answer: C

Rationale: Abnormal peripheral vasodilation is a change associated with liver failure that requires close monitoring of the patient's blood pressure.

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