Nursing Elites

1. A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?

• A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
• B. Discard the residual volume properly and record it as output on the client’s fluid balance record
• C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
• D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

Correct answer: A

Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.

2. A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

• A. Decrease in urine output
• B. Blood clots present in the urine
• C. Prescription for metformin
• D. A & B

Correct answer: D

Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.

3. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:

• A. Within 10 to 15 minutes after the injection.
• B. 1 hour after the injection.
• C. At any time, because timing of meals with lispro injections is unnecessary.
• D. 2 hours before the injection.

Correct answer: A

Rationale: The correct answer is to eat within 10 to 15 minutes after the injection. Insulin lispro, also known as Humalog, is a rapid-acting insulin that starts working very quickly. Eating shortly after the injection helps match the food intake with the insulin action, reducing the risk of hypoglycemia. Choice B is incorrect because waiting 1 hour after the injection may lead to a mismatch between insulin activity and food intake. Choice C is incorrect as timing meals with lispro injections is essential to optimize glycemic control. Choice D is incorrect as eating 2 hours before the injection is not in alignment with the rapid action of insulin lispro and may lead to fluctuations in blood sugar levels.

4. A client with chronic renal failure is receiving sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?

• A. Hyponatremia.
• B. Hypokalemia.
• C. Hyperkalemia.
• D. Hypocalcemia.

Correct answer: C

Rationale: Correct Answer: The correct answer is C, 'Hyperkalemia.' Sodium polystyrene sulfonate (Kayexalate) is a medication used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Therefore, the nurse should monitor the client for changes in potassium levels to assess the effectiveness of the medication and prevent potential complications related to hyperkalemia. Choice A, 'Hyponatremia,' is incorrect as Kayexalate does not primarily affect sodium levels. Choice B, 'Hypokalemia,' is incorrect as Kayexalate is used to treat high potassium levels, not low. Choice D, 'Hypocalcemia,' is incorrect as Kayexalate does not directly impact calcium levels.

5. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient’s admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct?

• A. Administer the digoxin and monitor the patient’s electrocardiogram closely.
• B. Hold the digoxin dose and notify the provider of the patient’s lab values.
• C. Request an order for an intravenous bolus of potassium.
• D. Request an order for oral potassium supplements.

Correct answer: B

Rationale: In the scenario presented, the patient has a low serum potassium level, which can predispose the patient to digoxin toxicity. It is essential for the nurse to hold the digoxin dose and promptly notify the healthcare provider of the abnormal lab values. Option A is incorrect because administering digoxin without addressing the low potassium level can potentiate toxicity. Option C is inappropriate as potassium should not be given as an IV bolus, especially in the case of hypokalemia. Option D is incorrect because oral potassium supplements may not be sufficient for rapidly correcting severe hypokalemia in an acute care setting.

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