Nursing Elites

1. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:

• A. Verify correct placement of the tube
• B. Check that the feeding solution matches the dietary order
• C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
• D. Ensure that the feeding solution is at room temperature

Correct answer: A

Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach. Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm. Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement. Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.

2. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

• A. Check vital signs
• B. Massage the fundus
• C. Offer a bedpan
• D. Check for perineal lacerations

Correct answer: B

Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.

3. When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?

• A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
• B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
• C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
• D. This is a question that should be directed to your healthcare provider.

Correct answer: C

Rationale: Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.

4. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

• A. Rice
• B. Oatmeal
• C. Rye toast
• D. White bread

Correct answer: A

Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.

5. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

• A. Prone position
• B. On the stomach
• C. Left lateral position
• D. Right lateral position

Correct answer: C

Rationale: After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.

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