Nursing Elites

1. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

• A. Drainage fluid is greenish-yellow
• B. Aspirate pH of 3
• C. Abdominal rigidity
• D. Air bubbles noted in the NG tube

Correct answer: C

Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.

2. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?

• A. A wheelchair
• B. A stand-assist lift
• C. A transfer belt
• D. A slide board

Correct answer: B

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.

3. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: The correct answer is C: 'Tell me how often you drink alcohol.' Alcohol use can exacerbate aggressive behaviors and is relevant for the assessment of suicide risk in adolescents with conduct disorders. Choices A, B, and D are unrelated to the assessment of suicide risk in this scenario and do not provide information that directly impacts the client's risk assessment.

4. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?

• A. Blood pressure
• B. Respiratory rate
• C. Heart rate
• D. Temperature

Correct answer: B

Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.

5. A nurse is providing teaching to a client who has chronic kidney failure and an AV fistula for hemodialysis with a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching?

• A. Reduces blood pressure
• B. Inhibits clotting of fistula
• C. Promotes RBC production
• D. Stimulates growth of neutrophils

Correct answer: C

Rationale: The correct answer is C: Promotes RBC production. Epoetin alfa stimulates red blood cell production, which is important for clients with chronic kidney disease who may have anemia due to decreased erythropoietin production by the kidneys. Options A, B, and D are incorrect: epoetin alfa does not directly reduce blood pressure, inhibit clotting of the fistula, or stimulate growth of neutrophils.

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