Nursing Elites

1. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

2. A client has a new diagnosis of hyperthyroidism and is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of iodine-rich foods.
• B. You should avoid foods that contain iodine.
• C. You should increase your intake of dairy products.
• D. You should avoid foods that contain gluten.

Correct answer: B

Rationale: The correct answer is B. In hyperthyroidism, it is advisable to avoid foods that contain iodine to help manage the condition and prevent complications. Excessive iodine intake can exacerbate hyperthyroidism symptoms by stimulating the thyroid gland. Therefore, the nurse should include information about avoiding iodine-rich foods in the client's dietary management teaching. Choices A, C, and D are incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism symptoms, increasing dairy products is not specific to managing hyperthyroidism, and avoiding gluten is more relevant for conditions like celiac disease, not hyperthyroidism.

3. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

4. A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?

• A. Hypotension.
• B. Bradycardia.
• C. Crackles in the lungs.
• D. Flat neck veins.

Correct answer: C

Rationale: Crackles in the lungs are a classic sign of fluid volume overload. When there is an excess of fluid in the lungs, it can manifest as crackling sounds upon auscultation. This finding indicates the accumulation of fluid in the alveoli and interstitial spaces of the lungs, which is a common manifestation of fluid volume overload.

5. What is a true statement about caring for a client with a nasogastric (NG) tube?

• A. The NG tube should be flushed with 30 mL of water every 4 hours.
• B. The client should be positioned in a supine position.
• C. The NG tube should be advanced 5 cm if resistance is met.
• D. The client's nasal mucosa should be inspected daily.

Correct answer: A

Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.

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