Nursing Elites

1. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

2. When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?

• A. Listen to the parents' description of the child's behavior.
• B. Compare the child's function from one occasion to another.
• C. Engage the parents in a discussion about the child's feelings.
• D. Determine the child's mental status through direct questioning.

Correct answer: B

Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.

3. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

4. Which method is used to verify the placement of a newly inserted central venous access device (CVAD)?

• A. Chest x-ray
• B. Flushing the line with heparin
• C. Withdrawing blood to ensure patency
• D. Chest fluoroscopy

Correct answer: A

Rationale: The correct method to verify the placement of a newly inserted central venous access device (CVAD) is a chest x-ray. This is crucial to detect any potential complications such as pneumothorax, which can occur during subclavian vein catheter insertion. Symptoms of pneumothorax may include shortness of breath and anxiety. Flushing the line with heparin is not used for placement verification, but rather for maintaining patency after verification. Withdrawing blood to ensure patency is done after placement is confirmed, not for initial verification. Chest fluoroscopy may be used during the insertion process but is not typically employed for placement verification.

5. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?

• A. Feelings of guilt
• B. Need to control others
• C. Desire for punishment
• D. Excessive physical activity

Correct answer: D

Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.

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