Nursing Elites

1. What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?

• A. Check tube placement before each feeding
• B. Flush the tube with water before and after each feeding
• C. Elevate the head of the bed to 30 degrees
• D. Administer the feeding at room temperature

Correct answer: A

Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.

2. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

• A. Apply an ice pack
• B. Document the findings and monitor
• C. Notify the surgeon
• D. Clean the wound with sterile saline

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

3. The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. What is the priority nursing intervention?

• A. Suction the tracheostomy as needed
• B. Ensure the tracheostomy ties are secure
• C. Provide humidified oxygen
• D. Clean any exudate around the tracheostomy site

Correct answer: A

Rationale: The priority nursing intervention for a client with a tracheostomy on mechanical ventilation is to suction the tracheostomy as needed. Suctioning is essential to maintain a clear airway and prevent respiratory distress. While ensuring tracheostomy ties are secure (choice B) is important, it is not as urgent as airway maintenance. Providing humidified oxygen (choice C) is beneficial but does not address the immediate need for airway clearance. Cleaning exudate around the tracheostomy site (choice D) is important for hygiene but takes precedence over ensuring airway patency through suctioning.

4. The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?

• A. 15 degrees
• B. 30 degrees
• C. 45 degrees
• D. 90 degrees

Correct answer: C

Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.

5. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?

• A. Continue the transfusion at a slower rate
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.

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