Nursing Elites

1. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?

• A. An x-ray shows the end of the tube above the pylorus.
• B. The tube is aspirated and contains clear gastric fluid.
• C. The tube is flushed with sterile water without resistance.
• D. The client does not cough or choke during tube insertion.

Correct answer: B

Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.

2. A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?

• A. 8 oz of ice chips
• B. 8 oz of ice chips
• C. 1 cup of broth
• D. 1 cup of broth

Correct answer: A

Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.

3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Census overdue

Correct answer: A

Rationale: The correct answer is A: Temperature. A high fever is a significant indicator of infection or other serious conditions, making it the priority finding. Elevated temperature indicates an immediate concern for infection, which can quickly escalate and lead to severe complications if not addressed promptly. While heart rate, abdominal tenderness, and census overdue are important aspects to consider in the client's care, addressing the fever takes precedence due to its potential severity and implications for the client's health.

4. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

• A. Carbon monoxide does not have a distinct odor.
• B. Water heaters should be inspected every 5 years.
• C. The lungs are not damaged from carbon monoxide inhalation.
• D. Carbon monoxide binds with hemoglobin in the body.

Correct answer: D

Rationale: The correct answer is D: 'Carbon monoxide binds with hemoglobin in the body.' Carbon monoxide is an odorless, colorless gas, so it does not have a distinct odor (Choice A). While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning (Choice B). Carbon monoxide primarily affects the cardiovascular system by binding with hemoglobin, reducing the blood's ability to carry oxygen, rather than causing direct lung damage (Choice C). Understanding how carbon monoxide binds with hemoglobin is crucial in recognizing the mechanism of poisoning and its potential consequences.

5. The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rhythm
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.

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