Nursing Elites

1. A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?

• A. Semi-Fowlers
• B. Supine
• C. Reverse Trendelenburg
• D. High Fowler’s

Correct answer: D

Rationale: Placing the client in a high Fowler’s position helps prevent aspiration and promotes proper digestion and feeding tube function.

2. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

• A. Obtain daily weights.
• B. Measure abdominal girth.
• C. Keep strict intake and output.
• D. Encourage her to increase fluids.

Correct answer: B

Rationale: For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.

3. The nurse aspirates 40 mL of undigested formula from the client’s nasogastric tube. Before administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be

• A. Discarded properly and recorded as output on the client’s intake and output record.
• B. Poured into the nasogastric tube through a syringe with the plunger removed.
• C. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed.
• D. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger.

Correct answer: B

Rationale: After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.

4. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

• A. Erythrocyte sedimentation rate
• B. Serum bilirubin
• C. Hemoglobin
• D. Blood urea nitrogen

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

5. Which of the following symptoms is a client with colon cancer most likely to exhibit?

• A. A change in appetite
• B. A change in bowel habits
• C. An increase in body weight
• D. An increase in body temperature

Correct answer: B

Rationale: A change in bowel habits is the most common symptom of colon cancer.

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