Nursing Elites

1. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?

• A. Auscultate the client's lungs for breath sounds
• B. Check the client's blood glucose level
• C. Monitor the client's bowel sounds
• D. Elevate the head of the bed to 45 degrees

Correct answer: D

Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.

2. A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?

• A. 2 liters per minute
• B. 4 liters per minute
• C. 6 liters per minute
• D. 8 liters per minute

Correct answer: B

Rationale: The correct answer is 4 liters per minute. Without a healthcare provider's order, the nurse should administer a maximum of 4 liters per minute of oxygen to prevent carbon dioxide retention in COPD clients. Higher flow rates can lead to oxygen toxicity and worsen the client's condition. Choices A, C, and D exceed the safe limit for oxygen administration without a healthcare provider's order.

3. The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer nitroglycerin sublingually as prescribed.
• C. Obtain an electrocardiogram (ECG).
• D. Assess the client's level of consciousness.

Correct answer: C

Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.

4. The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely?

• A. Serum calcium
• B. Serum triglycerides
• C. Serum glucose
• D. Serum triglycerides

Correct answer: B

Rationale: Serum triglycerides should be monitored closely in a client receiving TPN as they may indicate hyperlipidemia, which is a potential complication of TPN. Monitoring serum triglycerides is essential to prevent complications such as hypertriglyceridemia. Serum calcium and glucose levels are also important to monitor in clients receiving TPN, but in this scenario, serum triglycerides take priority due to the risk of hyperlipidemia.

5. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?

• A. Explain that this is an expected occurrence with aging.
• B. Observe the lower extremities for signs of muscle atrophy.
• C. Review the medical record for recent diagnostic test results.
• D. Ask the client to describe the changes that have occurred.

Correct answer: D

Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.

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