Nursing Elites

1. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

• A. measure intake and output.
• B. check albumin levels.
• C. monitor glucose levels.
• D. increase enteral feeding.

Correct answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

2. What is the most appropriate feeding method for a client who is unable to swallow?

• A. Nothing by mouth
• B. Nasogastric feedings
• C. Clear liquids
• D. Total parenteral nutrition

Correct answer: B

Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.

3. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:

• A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
• B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
• C. request that the family have a seat in the station rather than stand while awaiting its loved one.
• D. request that the family wait for its loved one in the Emergency Department waiting room.

Correct answer: A

Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality. Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality. Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information. Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.

4. Which of the following is responsible for laws mandating the reporting of certain infections and diseases?

• A. Centers for Disease Control and Prevention (CDC)
• B. individual state laws
• C. National Institutes of Health (NIH)
• D. Health and Human Services (HHS)

Correct answer: B

Rationale: Individual state laws mandate the reporting of infectious diseases. The list of reportable diseases varies from state to state and is overseen by state health departments. While the CDC plays a significant role in disease surveillance, reporting infectious diseases is primarily governed by individual state laws. The CDC's role is to provide support, guidance, and expertise to state health departments. The National Institutes of Health (NIH) primarily focus on biomedical and health-related research, not on mandating disease reporting. Health and Human Services (HHS) is a federal department that oversees various agencies, but the responsibility for mandating disease reporting lies with individual states.

5. A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

• A. Suctioning a client who requires periodic suctioning
• B. Assessing a client who has undergone an arteriogram and requires close monitoring
• C. Performing colostomy irrigation on a client with an ostomy
• D. Assisting a client who needs frequent ambulation with a walker

Correct answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.

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