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. While caring for a client with an arterial line, which of the following actions should the nurse take?

• A. Level the transducer with the client's phlebotomy site
• B. Flush the arterial line every 8 hours
• C. Obtain a blood sample for arterial blood gases
• D. Keep the client's hand elevated above the heart level

Correct answer: C

Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.

3. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

• A. Assess the client's pain level.
• B. Monitor the client's respiratory rate.
• C. Measure the client's blood pressure.
• D. Check the client's bowel sounds.

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

4. Which lab value should be monitored in patients receiving furosemide?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

5. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

• A. Sodium 144 mEq/L
• B. Potassium 5.2 mEq/L
• C. Bicarbonate 24 mEq/L
• D. Magnesium 1.9 mEq/L

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

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