Nursing Elites

1. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

2. When teaching a patient about the side effects of a new medication, which teaching method is most effective?

• A. Providing a written pamphlet
• B. Giving verbal instructions only
• C. Demonstrating how to take the medication
• D. Using a combination of verbal, written, and demonstration methods

Correct answer: D

Rationale: The most effective teaching method when educating a patient about the side effects of a new medication is to use a combination of verbal, written, and demonstration methods. This comprehensive approach ensures that the patient receives information through multiple channels, catering to different learning styles. Verbal instructions allow for direct communication, written materials provide a reference for the patient to review later, and demonstrations offer a visual aid that can enhance understanding. Providing a combination of these methods increases the likelihood of the patient retaining and comprehending the information effectively. Choices A, B, and C are less effective as they do not encompass the benefits of utilizing multiple teaching modalities.

3. A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?

• A. Go over the surgical procedure with the patient before he or she is anesthetized
• B. Strictly adhere to asepsis during all intraoperative procedures
• C. Provide emotional support to the patient and their family
• D. Monitor the patient’s physical status

Correct answer: A

Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.

4. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

5. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

• A. They are irregular
• B. They are usually felt in the abdomen
• C. They start in the back and radiate to the abdomen
• D. They become more intense during walking

Correct answer: B

Rationale: The correct statement about prelabor contractions (Braxton Hicks contractions) is that they are usually felt in the abdomen. They are irregular in nature and do not intensify with movement. Choice A is incorrect because prelabor contractions are irregular, not regular. Choice C is incorrect as prelabor contractions do not start in the back and radiate to the abdomen. Choice D is incorrect as prelabor contractions do not become more intense during walking.

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