Nursing Elites

1. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?

• A. Irrigate the NG tube with 30 ml of normal saline.
• B. Administer an antiemetic as prescribed.
• C. Assess the NG tube for patency and reposition if necessary.
• D. Provide sips of water and reassess the client's symptoms.

Correct answer: C

Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.

2. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?

• A. Assign a UAP to assist the client with a warm shower early in the morning.
• B. Administer anti-inflammatory medication before the procedure.
• C. Encourage the client to perform range-of-motion exercises.
• D. Reschedule the procedure for later in the day.

Correct answer: A

Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.

3. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?

• A. Explain that this is an expected occurrence with aging.
• B. Observe the lower extremities for signs of muscle atrophy.
• C. Review the medical record for recent diagnostic test results.
• D. Ask the client to describe the changes that have occurred.

Correct answer: D

Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.

4. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 100/60 mmHg
• C. Crackles in the lungs
• D. Presence of a new murmur

Correct answer: C

Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.

5. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods.
• B. Report increased bruising or bleeding.
• C. Stop medication if a cough develops.
• D. Limit intake of leafy green vegetables.

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.

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