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 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

• A. Perform an otoscopic examination
• B. Measure the child's abdominal girth
• C. Collect a urine specimen for routine urinalysis
• D. Obtain a blood specimen for serum electrolytes

Correct answer: C

Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.

3. The nurse is assessing a client with left-sided heart failure. Which laboratory value is most concerning?

• A. Serum creatinine of 1.5 mg/dL
• B. Serum sodium of 136 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Hemoglobin of 12 g/dL

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client with left-sided heart failure as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias, which can exacerbate heart failure. Serum creatinine of 1.5 mg/dL is slightly elevated but not as immediately concerning as hyperkalemia. Serum sodium of 136 mEq/L is within the normal range. Hemoglobin of 12 g/dL is also within the normal range and not directly related to the client's left-sided heart failure.

4. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Perform deep suctioning every 2 to 4 hours.
• B. Encourage the client to drink plenty of fluids.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.

5. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

• A. Auscultate the client's bowel sounds
• B. Observe for edema around the ankles
• C. Measure the client's capillary glucose level
• D. Count the apical and radial pulses simultaneously

Correct answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

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