Nursing Elites

1. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?

• A. Increase the suction on the NG tube.
• B. Administer an antiemetic as prescribed.
• C. Irrigate the NG tube with saline.
• D. Reposition the client to the left side.

Correct answer: B

Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.

2. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

3. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

• A. Glucose should be taken if I have a fruity breath odor.
• B. Glucose should be taken if I am urinating more than usual.
• C. Glucose should be taken if I have blurred vision.
• D. Glucose should be taken if I develop shakiness.

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

4. When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?

• A. Monitoring for signs of fluid overload.
• B. Ensuring the client receives enough fluids to prevent dehydration.
• C. Preventing electrolyte imbalances.
• D. Maintaining the prescribed rate of fluid administration.

Correct answer: A

Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.

5. The nurse and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the nurse implement?

• A. Demonstrate to the UAP how to approach the client from the client's left side
• B. Ask the UAP to leave the room and assess the client's body for bruising
• C. Carefully observe the interaction between the client and family members
• D. Instruct the UAP to protect the client's left side when transferring to a chair

Correct answer: A

Rationale: The correct action for the nurse to implement is to demonstrate to the UAP how to approach the client from the client's left side. Approaching the client from the neglected side (left side) can help in retraining the brain and improving awareness of the affected side, which is crucial in the management of neglect syndrome. Choice B is incorrect as assessing the client's body for bruising is not directly related to managing neglect syndrome. Choice C is incorrect as observing the interaction between the client and family members does not address the specific intervention needed for neglect syndrome. Choice D is incorrect because protecting the client's left side when transferring to a chair does not actively involve retraining the brain and improving awareness of the neglected side, which is the primary goal in managing neglect syndrome.

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