Nursing Elites

1. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?

• A. Elevate the head of the bed to 30-45 degrees.
• B. Check residual volumes every 4 hours.
• C. Verify tube placement every shift.
• D. Flush the tube with water every 4 hours.

Correct answer: A

Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.

2. The healthcare professional is preparing to administer a medication through a nasogastric (NG) tube. Which action should the healthcare professional take to ensure proper administration?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Administer the medication with food to prevent nausea.
• C. Verify tube placement by aspirating stomach contents.
• D. Dilute the medication with normal saline before administration.

Correct answer: A

Rationale: Flushing the NG tube with water before and after medication administration is essential to ensure the tube is patent and prevent clogging. This action helps in clearing the tube and ensures that the medication is delivered properly. Administering medication with food (Choice B) may not be appropriate for all medications and can interfere with their absorption. Verifying tube placement by aspirating stomach contents (Choice C) is important but does not directly relate to ensuring proper medication administration. Diluting the medication with normal saline (Choice D) is not a standard practice for administering medications through an NG tube.

3. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

• A. Administer analgesics to the child on a routine schedule throughout the day and night.
• B. Offer fluids to the child immediately after surgery.
• C. Allow the child to return to solid foods gradually.
• D. Avoid administering any medication until the child is fully awake.

Correct answer: A

Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.

4. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?

• A. Absent bowel sounds
• B. Pain level of 8/10
• C. Temperature of 100.4°F
• D. Saturated abdominal dressing

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.

5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

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