Nursing Elites

1. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?

• A. Pulverize all medications into a powdery condition
• B. Squeeze the tube before using it to break up stagnant liquids
• C. Cleanse the skin around the tube daily with hydrogen peroxide
• D. Flush adequately with water before and after using the tube

Correct answer: D

Rationale: For a client with a percutaneous endoscopic gastrostomy (PEG) tube, flushing the tube adequately with water before and after use is essential. This action helps prevent clogging and ensures the proper administration of feedings and medications. Choice A is incorrect because pulverizing all medications into a powdery condition is not necessary for PEG tube administration. Choice B is incorrect as squeezing the tube to break up stagnant liquids may damage the tube. Choice C is incorrect because cleansing the skin around the tube daily with hydrogen peroxide can be too harsh and lead to skin irritation.

2. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?

• A. Check the protein level in urine
• B. Have the client turn to the left side
• C. Take the temperature
• D. Monitor the urine output

Correct answer: B

Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.

3. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

• A. Abdominal x-ray
• B. Auscultation
• C. Flushing tube with saline
• D. Aspiration for gastric contents

Correct answer: D

Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.

4. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?

• A. Protamine
• B. Amicar
• C. Imferon
• D. Diltiazem

Correct answer: A

Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).

5. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 90 beats per minute
• B. A blood pressure of 120/80 mm Hg
• C. A respiratory rate of 16 breaths per minute
• D. A temperature of 98.6 degrees Fahrenheit

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

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