Nursing Elites

1. A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?

• A. Nausea and vomiting
• B. Normal bowel sounds
• C. Weight gain
• D. Decreased abdominal distention

Correct answer: D

Rationale: The correct answer is D: Decreased abdominal distention. This finding indicates that the client is tolerating the feeding well without experiencing bloating or discomfort. Nausea and vomiting (choice A) are symptoms of intolerance to enteral feedings. Normal bowel sounds (choice B) are a good sign but do not directly indicate tolerance to the feeding. Weight gain (choice C) may occur due to factors other than enteral feedings.

2. A nurse is monitoring a client who is receiving continuous enteral feedings. What is a sign of intolerance to the feeding?

• A. Weight gain
• B. Nausea
• C. Constipation
• D. Decreased heart rate

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain (Choice A) is not typically a sign of intolerance to enteral feedings but may indicate other health issues. Constipation (Choice C) is not a common sign of feeding intolerance. Decreased heart rate (Choice D) is not typically associated with intolerance to enteral feedings.

3. A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

• A. Use pursed-lip breathing during activities
• B. Avoid physical activity
• C. Perform weight-bearing exercises
• D. Use a humidifier while sleeping

Correct answer: A

Rationale: Corrected Rationale: The nurse should instruct the client to use pursed-lip breathing during activities to help improve oxygenation. Pursed-lip breathing can keep the airways open longer, facilitating better oxygen exchange and making it easier to exhale carbon dioxide. Choice B is incorrect as physical activity, within the client's limitations, is beneficial for maintaining overall health. Choice C is incorrect as weight-bearing exercises are important for bone health but not directly related to improving oxygenation in COPD. Choice D is incorrect as using a humidifier while sleeping can help with moisture in the airways but does not directly impact oxygenation in COPD.

4. When performing an abdominal assessment on a client, what action should the nurse take first?

• A. Palpate the abdomen
• B. Auscultate bowel sounds
• C. Inspect the abdomen
• D. Percuss the abdomen

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.

5. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?

• A. Wear non-sterile gloves
• B. Apply sterile gloves over non-sterile gloves
• C. Change gloves if the sterile solution splashes onto the sterile field
• D. Cover the sterile field with a sterile drape

Correct answer: C

Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.

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