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. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

3. After completing an assessment and determining that a client has a problem, what should the LPN/LVN do next?

• A. Determine the etiology of the problem.
• B. Prioritize nursing care interventions.
• C. Plan appropriate interventions.
• D. Collaborate with the client to set goals.

Correct answer: A

Rationale: After identifying a problem in a client, the next step for the LPN/LVN is to determine the etiology or cause of the problem. Understanding the root cause of the issue is essential as it guides the development of appropriate interventions. Option B, prioritizing nursing care interventions, is premature without knowing the cause of the problem. Option C, planning appropriate interventions, also relies on knowing the etiology first to ensure the interventions directly address the underlying issue. Collaborating with the client to set goals, as mentioned in option D, is important but typically comes after understanding the cause of the problem to ensure the goals are relevant and effective.

4. Which patient will lead the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

• A. A patient who is completely immobile
• B. A patient who is not completely immobile
• C. A patient at risk for single-system involvement
• D. A patient who is at risk for multisystem problems

Correct answer: B

Rationale: The correct answer is B because the nursing diagnosis of Impaired physical mobility is appropriate for a patient who has some limitations in mobility but is not completely immobile. Choice A is incorrect as a patient who is completely immobile would not have impaired physical mobility but rather no physical mobility at all. Choices C and D are also incorrect as they do not directly relate to the defining characteristics of Impaired physical mobility, which involve limitations in movement and physical activity.

5. The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?

• A. Spinach
• B. Bananas
• C. Chicken
• D. Rice

Correct answer: A

Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.

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