Nursing Elites

1. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

2. A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?

• A. Avoid lying down after meals
• B. Eat large meals to reduce acid production
• C. Drink carbonated beverages with meals
• D. Consume spicy foods to improve digestion

Correct answer: A

Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.

3. What is the first step in preparing a blood transfusion?

• A. Administer the blood via IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Administer diuretics to prevent fluid overload

Correct answer: B

Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.

4. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

5. How should a healthcare professional monitor a patient receiving IV potassium?

• A. Monitor ECG for dysrhythmias
• B. Monitor urine output
• C. Monitor serum potassium levels
• D. All of the above

Correct answer: D

Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.

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