Nursing Elites

1. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?

• A. Check for the presence of bowel sounds every 8 hours.
• B. Flush the NG tube every 24 hours.
• C. Provide the client with sips of water every 2 hours.
• D. Keep the client's head of the bed elevated to 45 degrees.

Correct answer: D

Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.

2. A client at 10 weeks of gestation with a history of UTIs is receiving teaching from a nurse. Which of the following statements should the nurse include?

• A. You should drink 240 ml (8 oz) of water before and after intercourse.
• B. You should avoid drinking orange juice because it increases the risk of infection.
• C. You should empty your bladder after intercourse to help prevent infection.
• D. You should take a hot bath to help prevent infection.

Correct answer: C

Rationale: The correct statement the nurse should include is to advise the client to empty their bladder after intercourse to help prevent UTIs. Emptying the bladder after intercourse helps reduce the risk of UTIs by flushing bacteria from the urethra. Choice A is incorrect as drinking water before and after intercourse is not specifically related to preventing UTIs. Choice B is incorrect as there is no direct correlation between orange juice consumption and UTI risk. Choice D is incorrect as taking a hot bath can actually increase the risk of UTIs by promoting bacterial growth.

3. What is the most important nursing assessment post-surgery?

• A. Monitor vital signs
• B. Monitor blood pressure
• C. Monitor the surgical site
• D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

4. A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings should the healthcare professional report to the provider?

• A. Urine output of 80 mL/hr
• B. Blood pressure of 140/90 mm Hg
• C. Serum creatinine 2.8 mg/dL
• D. Heart rate of 72/min

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 2.8 mg/dL indicates impaired kidney function and should be reported to the healthcare provider. Elevated serum creatinine levels are indicative of decreased kidney function and potential progression of chronic kidney disease. Choices A, B, and D are within normal ranges and do not signify immediate concerns related to kidney disease. Urine output of 80 mL/hr is appropriate, a blood pressure of 140/90 mm Hg is considered prehypertensive but not acutely concerning, and a heart rate of 72/min falls within the normal range.

5. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should have my vision checked regularly while taking this medication.
• B. This medication can cause my urine to turn reddish-orange.
• C. I need to wear sunscreen and protective clothing while taking this medication.
• D. I will discontinue this medication if I experience nausea.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

Similar Questions