Nursing Elites

1. The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?

• A. Flush the tube with water every 4 hours
• B. Check the tube placement before each feeding
• C. Secure the tube to the client's nose with tape
• D. Keep the head of the bed elevated at 30 degrees

Correct answer: B

Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.

2. A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?

• A. Heart rate of 110 beats per minute
• B. Temperature of 99.5°F (37.5°C)
• C. Blood pressure of 88/52 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

3. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

• A. Heart rate of 122 bpm and respiratory rate of 28.
• B. Yellow sputum expectorated.
• C. Temperature of 100.5°F (38.1°C).
• D. Shortness of breath on exertion.

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

4. A client is prescribed an inhaled corticosteroid for asthma management. Which instruction should the nurse provide to the client regarding the use of this medication?

• A. Rinse your mouth after using the inhaler
• B. Hold your breath for 5 seconds after inhaling the medication
• C. Use the inhaler during an acute asthma attack
• D. Take the medication only when symptoms occur

Correct answer: A

Rationale: The correct instruction for a client using an inhaled corticosteroid for asthma management is to rinse the mouth after using the inhaler. This helps prevent oral thrush, a common side effect of corticosteroid inhalers. Holding the breath for 5 seconds after inhaling the medication (Choice B) is not necessary for corticosteroid inhalers. Using the inhaler during an acute asthma attack (Choice C) is not the purpose of corticosteroids, which are used for long-term asthma management. Taking the medication only when symptoms occur (Choice D) is not correct as corticosteroids are typically used regularly to control asthma symptoms.

5. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

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