Nursing Elites

1. During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?

• A. Potassium 5.5 mEq/L
• B. Irritation of nasal mucosa
• C. Sodium 144 mEq/L
• D. Loose stools

Correct answer: B

Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.

2. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials?

• A. Solid foods are introduced one at a time beginning with cereal.
• B. Finely ground meat should be avoided early to provide iron.
• C. Egg white is not recommended early to increase protein intake.
• D. Solid foods should not be mixed with formula in a bottle.

Correct answer: A

Rationale: The correct answer is A. Introducing solid foods one at a time, starting with cereal, is recommended to monitor for any food allergies or intolerances in infants. Choice B is incorrect as finely ground meat should be introduced later due to the risk of choking and is not necessary for iron intake. Choice C is incorrect as egg white should be avoided early due to the risk of allergies. Choice D is incorrect as solid foods should not be mixed with formula in a bottle to prevent overfeeding and promote healthy eating habits.

3. A nurse is caring for a group of clients. How should the nurse prevent the spread of infection?

• A. Place a client with TB in a negative pressure room.
• B. Use standard precautions only.
• C. Place a client with TB in a private room.
• D. Use barrier precautions only.

Correct answer: A

Rationale: The correct answer is to place a client with TB in a negative pressure room. Tuberculosis (TB) is an airborne infectious disease, and placing the client in a negative pressure room helps prevent the spread of the infection by containing and filtering the air within the room. Standard precautions (Choice B) are important for preventing the spread of infection in general, but specific precautions are needed for airborne diseases like TB. Placing the client in a private room (Choice C) may not provide adequate ventilation and containment of airborne pathogens. Using barrier precautions (Choice D) alone is not sufficient for preventing the airborne transmission of TB.

4. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?

• A. Flush the tube with 30 ml of water before and after medication administration.
• B. Secure the tube to the client's gown.
• C. Check the placement of the tube by auscultation.
• D. Irrigate the tube with normal saline every shift.

Correct answer: A

Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.

5. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?

• A. Albumin level of 3 g/dL
• B. Hemoglobin level of 12 g/dL
• C. WBC count of 6,000/mm³
• D. Blood glucose level of 100 mg/dL

Correct answer: A

Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.

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