Nursing Elites

1. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?

• A. Flush the tube with 50 mL of normal saline every 8 hours
• B. Clamp the tube when not in use
• C. Position the client in a supine position
• D. Verify tube placement by checking pH of gastric contents

Correct answer: D

Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.

2. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?

• A. Two liters.
• B. Three liters.
• C. Four liters.
• D. Five liters.

Correct answer: B

Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.

3. After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first?

• A. Reorient the client to the room
• B. Place an eye patch on one eye
• C. Evaluate the client's ability to swallow
• D. Perform range of motion exercises

Correct answer: C

Rationale: Evaluating the client's ability to swallow is the priority intervention in this scenario. Pontine myelinolysis can affect neurological functions, including swallowing ability, putting the client at risk for aspiration. Assessing the client's ability to swallow will help prevent complications such as aspiration pneumonia. Reorienting the client to the room, placing an eye patch, or performing range of motion exercises are not as critical as ensuring the client can safely swallow.

4. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

5. While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?

• A. Irritation of nerve endings
• B. Diminished blood flow
• C. Ischemic tissue changes
• D. Compression of a nerve

Correct answer: D

Rationale: The correct answer is D: Compression of a nerve. In carpal tunnel syndrome, pain arises from the compression of the median nerve within the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. Choices A, B, and C are incorrect because carpal tunnel syndrome pain is primarily caused by the physical compression of the nerve, rather than irritation of nerve endings, diminished blood flow, or ischemic tissue changes.

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