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. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

• A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
• B. Use a mechanical lift
• C. Twist at the waist while holding the client
• D. Ask for assistance from another staff member

Correct answer: A

Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.

3. When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?

• A. Outer skin layer becomes less resilient.
• B. Less frequent bathing may be required.
• C. Skin becomes more subject to bruising.
• D. Sweat glands become less active.

Correct answer: B

Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.

4. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

5. The client with chronic obstructive pulmonary disease (COPD) is being educated about lifestyle changes. Which statement by the client indicates a need for further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with COPD should limit alcohol intake, not just to weekends, to effectively manage their condition. Excessive alcohol consumption can worsen respiratory symptoms and interfere with medications. Choices A, B, and D are all appropriate and beneficial for clients with COPD. Salt intake reduction helps in managing fluid retention and blood pressure. Regular exercise improves lung function and overall health. Monitoring blood pressure is crucial for individuals with COPD as hypertension is a common comorbidity.

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