Nursing Elites

1. 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.

2. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

• A. Administer a protein supplement
• B. Increase protein intake in the client's diet
• C. Increase IV fluid intake to improve hydration
• D. Cleanse the wound from the center outwards

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

3. What are the signs and symptoms of a potential infection?

• A. Fever, chills, and increased heart rate
• B. Increased white blood cell count and fever
• C. Shortness of breath and confusion
• D. Sweating and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Fever, chills, and increased heart rate are classic signs of an infection. These symptoms indicate the body's response to an invading pathogen. Choice B, 'Increased white blood cell count and fever,' is not a primary symptom that a person would typically notice themselves, and white blood cell count needs to be tested. Choice C, 'Shortness of breath and confusion,' may indicate other conditions like heart or lung issues rather than a general infection. Choice D, 'Sweating and low blood pressure,' are not specific to infections and can be caused by various factors like heat or dehydration.

4. What is an early sign that suctioning is needed for a client with a tracheostomy?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased oxygen saturation

Correct answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

5. A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?

• A. Apply heat to the affected area
• B. Place the client in a prone position
• C. Turn and reposition the client every 2 hours
• D. Provide the client with a bedpan every 4 hours

Correct answer: C

Rationale: The correct intervention for a client at risk for pressure ulcers is to turn and reposition the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and reducing the risk of pressure ulcer development. Applying heat to the affected area (Choice A) can increase the risk of skin breakdown. Placing the client in a prone position (Choice B) can also increase pressure on certain areas, leading to pressure ulcers. Providing the client with a bedpan every 4 hours (Choice D) is not directly related to preventing pressure ulcers.

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