Nursing Elites

1. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?

• A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
• B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
• C. The client mixes each medication separately in warm water.
• D. The client mixes their medications with their tube-feeding formula.

Correct answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

2. An appraisal of self-care practices involves an assessment of:

• A. all diagnostic tests.
• B. home treatment practices, including nurse visits for the sick or disabled.
• C. the family's capability to get health insurance.
• D. caregiving needs and the potential for strain.

Correct answer: D

Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.

3. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. lettuce
• B. eggs
• C. chocolate
• D. butterscotch

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce, eggs, and butterscotch do not affect LES pressure and are less likely to trigger heartburn in individuals with GERD. Therefore, clients who are prone to developing heartburn due to GERD should avoid consuming chocolate to manage their symptoms effectively.

4. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

5. A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

• A. Placing a tape measure around the widest point of the lower leg
• B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
• C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
• D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

Correct answer: A

Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.

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