Nursing Elites

1. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed 45 degrees during feedings.
• B. Place the client in the left lateral position for 30 minutes after feedings.
• C. Flush the tube with 30 mL of sterile water before each feeding.
• D. Check gastric residuals every 8 hours.

Correct answer: A

Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.

2. A nurse is caring for a client who has a pressure ulcer. Which of the following findings should the nurse report to the provider?

• A. Eschar
• B. Slough
• C. Granulation tissue
• D. Undermining

Correct answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

3. A nurse is assessing a client who has myasthenia gravis. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased muscle strength.
• C. Diarrhea.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: The correct answer is D: Decreased deep tendon reflexes. In myasthenia gravis, muscle weakness is a common manifestation, leading to decreased deep tendon reflexes. Bradycardia (choice A) is not typically associated with myasthenia gravis. Increased muscle strength (choice B) is unlikely as muscle weakness is a hallmark of this condition. Diarrhea (choice C) is not a typical finding in myasthenia gravis.

4. A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administering the medication.
• B. Insert the needle at a 45° angle.
• C. Use a Z-track technique to administer the injection.
• D. Aspirate for blood before injecting the medication.

Correct answer: C

Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.

5. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Clay-colored stools.
• B. Hypertension.
• C. Stridor.
• D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

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