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 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

• A. Further evaluation involving surgery may be needed
• B. A pelvic exam is also needed before cancer is ruled out
• C. Pap smear evaluation should be continued every six months
• D. One additional negative Pap smear in six months is needed

Correct answer: A

Rationale: In a 60-year-old female client with a family history of ovarian cancer and an abdominal mass, further evaluation involving surgery may be needed to rule out ovarian cancer. The presence of an abdominal mass raises suspicion for a possible malignancy, and a negative Pap smear result does not rule out ovarian cancer. A pelvic exam alone may not provide sufficient information to confirm or rule out ovarian cancer. Continuing Pap smear evaluations every six months or waiting for one additional negative Pap smear in six months is not appropriate in this scenario, as the abdominal mass requires immediate attention and further evaluation.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer intravenous insulin as prescribed.
• B. Monitor the client's urine output.
• C. Administer intravenous fluids.
• D. Administer 50% dextrose IV push.

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Headache
• C. Elevated blood pressure
• D. Low urine output

Correct answer: C

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. This finding can indicate worsening hypertension, which requires prompt intervention to prevent complications such as cardiovascular events or further kidney damage. Increased fatigue (Choice A) is a common symptom in CKD and can be expected with the condition itself or the treatment. Headache (Choice B) can also occur but is less specific to CKD or its treatment. Low urine output (Choice D) is a concern in CKD but may not be directly related to erythropoietin therapy.

5. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab test is important for the nurse to review before contacting the healthcare provider?

• A. Capillary glucose
• B. Urine specific gravity
• C. Serum calcium
• D. White blood cell count

Correct answer: C

Rationale: The correct answer is C: Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia. Serum calcium levels should be reviewed as they play a crucial role in diagnosing and managing hypocalcemia. Option A, capillary glucose, is not relevant to the symptoms described. Option B, urine specific gravity, is not typically used to assess numbness and tingling. Option D, white blood cell count, is unrelated to the symptoms presented by the client.

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