Nursing Elites

1. What is the most appropriate strategy for a client with an NG tube who is experiencing nausea and decreased gastric secretions?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: Irrigating the NG tube with sterile water is the most appropriate strategy for a client with an NG tube experiencing nausea and decreased gastric secretions. This intervention helps in relieving blockages within the tube and can help reduce nausea by ensuring proper drainage. Increasing the suction pressure (Choice A) can lead to complications and should not be done without healthcare provider orders. Turning the client onto their side (Choice C) is a general measure for patient comfort but does not directly address the issue with the NG tube. Replacing the NG tube with a new one (Choice D) is not necessary unless there are specific indications like tube damage or dislodgement.

2. What is the process for taking a telephone order from a provider?

• A. Patient name, drug, dose, route, frequency
• B. Read back for accuracy
• C. Have a witness listen to the order
• D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

3. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

4. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

5. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

• A. WBC count 2,900 /mm3.
• B. Fasting blood glucose 100 mg/dl.
• C. Hgb 14 g/dl.
• D. Heart rate 58/min.

Correct answer: A

Rationale: A WBC count of 2,900/mm3 indicates leukopenia, which is a serious side effect of clozapine and contraindicates its use. Leukopenia is a significant concern with clozapine therapy due to the risk of agranulocytosis, a potentially life-threatening condition. Monitoring the WBC count is crucial to detect this adverse effect early. The other options (B, C, and D) are within normal ranges and not contraindications for administering clozapine.

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