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. Postoperative client with fluid volume deficit. Which change indicates successful treatment?

• A. Decrease in heart rate
• B. Increase in blood pressure
• C. Decrease in respiratory rate
• D. Increase in urine output

Correct answer: A

Rationale: A decrease in heart rate can indicate improved fluid balance and successful treatment of fluid volume deficit. When a client is experiencing fluid volume deficit, the heart rate typically increases as a compensatory mechanism to maintain cardiac output. As fluid volume is restored and the deficit is corrected, the heart rate should decrease back towards a normal range. Choices B, C, and D are less likely to be directly related to the successful treatment of fluid volume deficit. An increase in blood pressure may occur as a compensatory response to fluid volume deficit; a decrease in respiratory rate is not a typical indicator of fluid volume deficit correction; and an increase in urine output can be a sign of improved kidney function but may not directly reflect fluid volume status.

3. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit, the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

• A. Dystonia
• B. Akathisia
• C. Bradykinesia
• D. Tardive dyskinesia

Correct answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a potential side effect of long-term antipsychotic use, characterized by involuntary movements like lip smacking and repetitive, purposeless movements. Choice A, dystonia, presents with sustained or repetitive muscle contractions. Choice B, akathisia, involves motor restlessness and a compelling need to be in constant motion. Choice C, bradykinesia, refers to slowness of movement typically seen in Parkinson's disease, not lip smacking and teeth grinding, which are indicative of tardive dyskinesia.

4. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

• A. After the acute phase of the disease has passed.
• B. As soon as the ability to move is lost.
• C. Once the patient enters the rehab unit.
• D. When the patient requests it.

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

5. A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?

• A. Clean around the stoma with povidone-iodine.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Use clean technique when suctioning the tracheostomy.
• D. Change tracheostomy ties weekly.

Correct answer: B

Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.

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