Nursing Elites

1. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

2. What is the primary goal of palliative care?

• A. To cure the client's illness.
• B. To prolong the client's life.
• C. To provide comfort and improve the quality of life.
• D. To prepare the client for surgery.

Correct answer: C

Rationale: The primary goal of palliative care is to provide comfort and improve the quality of life for clients with serious illnesses. Palliative care aims to address physical, emotional, and spiritual needs to enhance overall well-being rather than focusing on curing the underlying illness, prolonging life, or preparing for surgery. It emphasizes symptom management, pain relief, and support for patients and their families to ensure a better quality of life during the course of their illness.

3. A healthcare professional is preparing to administer medications to a client who has an NG tube for continuous feedings. Which of the following actions should the healthcare professional take?

• A. Add crushed medications to the enteral feeding.
• B. Infuse each medication by gravity.
• C. Administer the medications through a syringe.
• D. Flush the NG tube with 5 mL of sterile water.

Correct answer: C

Rationale: Administering medications through a syringe is the correct action to take when a client has an NG tube for continuous feedings. This method ensures that each medication is delivered correctly and is not mixed with the enteral feeding, preventing drug interactions and ensuring proper administration of each medication. Adding crushed medications to the enteral feeding (Choice A) can lead to inaccurate dosing and potential drug interactions. Infusing each medication by gravity (Choice B) is not recommended as it may not ensure accurate delivery of the medication. Flushing the NG tube with sterile water (Choice D) is important but is not directly related to administering medications through the tube.

4. When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?

• A. Deltoid
• B. Ventrogluteal
• C. Vastus lateralis
• D. Dorsogluteal

Correct answer: C

Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.

5. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

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