Nursing Elites

1. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?

• A. Stop the feeding and provide IV fluids.
• B. Dilute the feeding to half strength and continue at the same rate.
• C. Reduce the feeding rate and monitor for improvement.
• D. Add fiber to the client's diet to resolve diarrhea.

Correct answer: B

Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.

2. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

• A. To observe the type and amount of nasogastric tube drainage
• B. Monitor the client for nausea or other complications
• C. Irrigate the nasogastric tube with the ordered irrigation solution
• D. Perform nostril and mouth care

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

3. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?

• A. Take the medication with food to avoid gastrointestinal upset.
• B. Monitor for signs of infection, such as a sore throat.
• C. Increase fluid intake to prevent dehydration.
• D. Avoid direct sunlight to prevent photosensitivity.

Correct answer: D

Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.

4. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?

• A. Peabody Picture Vocabulary Test
• B. The Modified Checklist for Autism in Toddlers (M-CHAT)
• C. Wechsler Preschool and Primary Scale of Intelligence
• D. Denver Developmental Screening Test

Correct answer: B

Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

5. A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?

• A. Administer antipyretics as ordered
• B. Take a blood culture before administering antibiotics
• C. Encourage fluid intake to prevent dehydration
• D. Monitor vital signs every hour

Correct answer: B

Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.

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