Nursing Elites

1. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

• A. Daily weight
• B. Gastric residual volumes
• C. Bowel sounds
• D. Urinary and stool output

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

2. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?

• A. Swollen and discolored penile shaft
• B. Prepuce extends over the head of the penis
• C. Leaking urine around the top of the catheter
• D. Moist and excoriated perineal skin folds

Correct answer: A

Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.

3. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the PN implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: During labor, muscle cramps are common due to prolonged muscle tension. The correct intervention to alleviate a cramp in the leg is to extend the leg and flex the foot. This action helps relieve the muscle spasm by stretching and contracting the muscles. Massaging the calf and foot (Choice A) may not be as effective in relieving the cramp as extending and flexing the leg. Elevating the leg above the heart (Choice B) is not necessary and may not directly address the cramp. Checking the pedal pulse (Choice C) is important for assessing circulation, but it does not directly address the muscle cramp.

4. You are teaching students about how hyperosmotic agents (osmotic diuretics) are used to treat intracranial pressure. Which of the following is NOT one of the functions of hyperosmotic agents?

• A. Reduces brain metabolism and systemic blood pressure
• B. Reduces cerebral edema
• C. Dehydrates the brain
• D. Draws fluids from extravascular spaces into the plasma

Correct answer: A

Rationale: Hyperosmotic agents primarily work by reducing cerebral edema, dehydrating the brain, and drawing fluids from extravascular spaces into the plasma. However, they do not have a direct effect on reducing brain metabolism or systemic blood pressure. Therefore, the correct answer is A. Choice B is correct as hyperosmotic agents do help in reducing cerebral edema. Choice C is accurate as hyperosmotic agents dehydrate the brain. Choice D is also true as these agents draw fluids from extravascular spaces into the plasma.

5. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

Similar Questions