Nursing Elites

1. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nursing assistant aspirates and measures the amount of gastric aspirate
• B. The nursing assistant elevates the head of the client’s bed 30 degrees
• C. The nursing assistant warms the formula to room temperature
• D. B, C

Correct answer: D

Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.

2. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

• A. The nurse repeats the information as indicated by the client’s questions
• B. The nurse teaches all the information needed by the client in one session
• C. The nurse uses a video to explain medical terms to the client
• D. The nurse waits until the client asks questions about the surgery

Correct answer: A

Rationale: Choice A is the correct answer because repeating information and addressing the client’s questions as they arise is an effective method for reinforcing learning in adults. This approach allows for immediate clarification and reinforcement of important points. Choice B is incorrect because teaching all the information in one session may be overwhelming for the client and hinder retention. Choice C is incorrect as using a video with medical terms may not necessarily address the client's specific questions or concerns. Choice D is also incorrect because waiting for the client to ask questions may lead to missed opportunities for providing crucial information and addressing uncertainties.

3. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.

4. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?

• A. Discontinue the use of steroid therapy immediately if symptoms develop.
• B. Take diuretics as needed to treat the dependent edema in ankles.
• C. Increase the intake of dietary sodium every day to decrease fluid retention.
• D. Report any decrease in daily weight during treatment to the healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Reporting a decrease in daily weight is crucial when managing nephritic syndrome as it can indicate worsening of the condition or dehydration. It is essential to monitor weight changes closely to assess the effectiveness of treatment and the client's fluid status. Choice A is incorrect because discontinuing steroid therapy abruptly can lead to complications; gradual tapering is usually recommended. Choice B is incorrect as diuretics should be taken as prescribed by the healthcare provider to manage fluid retention. Choice C is also incorrect because increasing dietary sodium can exacerbate fluid retention, which is counterproductive in nephritic syndrome.

5. The system used at the division level and forward comprises six basic modules. Which module is composed of four medical specialists and two vehicles?

• A. Patient holding squad
• B. Surgical squad
• C. Ambulance squad
• D. Area support squad

Correct answer: C

Rationale: The Ambulance Squad is the module composed of four medical specialists and two vehicles. This squad is responsible for providing medical care during transportation. Choices A, B, and D are incorrect as they do not match the description provided in the question. The Patient Holding Squad focuses on a different aspect of patient care, the Surgical Squad is more specialized in surgical procedures, and the Area Support Squad provides a different type of support.

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