Nursing Elites

1. When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?

• A. Elevate the head of the bed 60 to 90 degrees
• B. Administer an antiemetic
• C. Prepare the client for surgery
• D. Provide oral care

Correct answer: A

Rationale: Elevating the head of the bed to 60 to 90 degrees is essential when inserting an NG tube. This position helps facilitate the passage of the tube through the esophagus into the stomach and reduces the risk of aspiration. Administering an antiemetic may be necessary to control nausea or vomiting, but it is not the primary intervention when inserting an NG tube. Preparing the client for surgery is not indicated solely for the insertion of an NG tube. Providing oral care is important for maintaining oral hygiene but is not directly related to inserting an NG tube.

2. During a clinic visit, a client with a kidney transplant asks, 'What will happen if chronic rejection develops?' Which response is best for the nurse to provide?

• A. Dialysis would need to be resumed if chronic rejection becomes a reality.
• B. Immunosuppressive therapy would be intensified.
• C. A second transplant would be scheduled immediately.
• D. We would monitor your kidney function closely.

Correct answer: A

Rationale: The best response for the nurse to provide is that dialysis would need to be resumed if chronic rejection becomes a reality. Chronic rejection of a transplanted kidney can lead to kidney failure, necessitating the need for dialysis until another transplant is possible. Choice B is incorrect because although immunosuppressive therapy may be adjusted, the immediate concern is the potential need for dialysis. Choice C is incorrect because scheduling a second transplant immediately is not typically the first step following chronic rejection. Choice D is also incorrect as close monitoring of kidney function is essential but does not address the immediate need for dialysis if chronic rejection occurs.

3. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Complaint of headaches and stiff neck.
• B. Complaint of dizziness and nausea.
• C. Increased pain at the puncture site.
• D. Mild redness around the puncture site.

Correct answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

5. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

• A. Document the extent of the bruising in the medical record.
• B. Apply a cold compress to the area.
• C. Elevate the affected limb.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.

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