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. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning, she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Client's current mood and affect
• B. When the client last took medications for bipolar disorder
• C. History of previous suicide attempts
• D. Details of the medications ingested

Correct answer: D

Rationale: Determining the specific medications ingested is the priority for guiding immediate treatment in the Emergency Department. Knowing when the client last took medications and her current mood are also important, but the ingested medications are the most urgent information needed. The client's current mood and affect are crucial for assessing her immediate state, but the priority is to identify the substances she ingested to provide appropriate interventions. While understanding the history of previous suicide attempts is relevant for assessing the client's risk, the immediate focus should be on the medications taken during this specific incident.

3. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?

• A. Increase the client's sedative dose
• B. Encourage the client to express her feelings and provide emotional support
• C. Initiate breathing techniques to manage anxiety
• D. Administer anxiolytic medication to calm the client

Correct answer: B

Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.

4. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

• A. Monitor gastrointestinal pain
• B. Ask the client about pain levels
• C. Check the client's vital signs
• D. Assess for signs of bleeding

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

5. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?

• A. Administer diuretics as prescribed.
• B. Prepare the client for dialysis.
• C. Restrict the client’s fluid intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.

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