Nursing Elites

1. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse offer?

• A. Milk
• B. Vegetable juice
• C. Chicken broth
• D. Orange juice with pulp

Correct answer: C

Rationale: A clear liquid diet consists of easily digestible transparent liquids. Chicken broth is an appropriate choice as it meets the criteria of being clear and liquid, making it suitable for a clear liquid diet. Milk, vegetable juice, and orange juice with pulp are not considered clear liquids. Milk is not transparent, vegetable juice is not clear, and orange juice with pulp contains solid particles, all of which do not align with the requirements of a clear liquid diet.

2. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

3. A healthcare professional is preparing to administer a subcutaneous injection of insulin. Which of the following actions should the professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, inserting the needle at a 90-degree angle is appropriate. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Using a 1-inch needle is common for subcutaneous injections to reach the subcutaneous fat layer adequately. Tuberculin syringes are typically used for intradermal injections, not subcutaneous injections. Aspirating before injecting is not necessary for subcutaneous injections as it is primarily used for intramuscular injections to ensure the needle is not in a blood vessel.

4. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

• A. Monitor intake and output every 8 hours.
• B. Flush the feeding tube every 4 hours.
• C. Measure the client's temperature every 24 hours.
• D. Change the feeding bag and tubing every 72 hours.

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

5. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.

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