Nursing Elites

1. A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?

• A. Administer a refrigerated feeding.
• B. Increase the amount of water used to flush the tubing.
• C. Decrease the rate of the client's feedings.
• D. Instruct the client to move onto their right side.

Correct answer: C

Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.

2. A nurse is reviewing admission prescriptions for a group of clients. Which prescription should the nurse identify as complete?

• A. Furosemide 20 mg BID
• B. Aspirin 1 tablet daily
• C. Nitroglycerin transdermal patch
• D. Metoprolol 5 mg IV now

Correct answer: A

Rationale: The correct answer is A. A complete prescription should include the medication name (Furosemide), dosage (20 mg), and administration schedule (BID - twice daily). Choice B is missing the dosage of Aspirin, choice C lacks the dosage information for Nitroglycerin, and choice D does not specify the administration schedule for Metoprolol.

3. A healthcare provider is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the healthcare provider to delegate?

• A. Adjusting the flow rate of the client's oxygen tank.
• B. Collecting a urine sample.
• C. Measuring the client's pain level.
• D. Transporting a client to x-ray.

Correct answer: D

Rationale: The correct answer is 'D: Transporting a client to x-ray.' This task is appropriate for delegation to assistive personnel as it involves transferring the client safely from one location to another, which does not require the specialized skills of a healthcare provider. Adjusting the flow rate of the client's oxygen tank (Choice A) involves making clinical decisions that should be done by a licensed healthcare provider. Collecting a urine sample (Choice B) and measuring the client's pain level (Choice C) require critical thinking and assessment skills that are typically within the scope of practice of licensed healthcare providers, not assistive personnel.

4. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Use a 21-gauge needle for injection.
• B. Inject the medication into the client's deltoid muscle.
• C. Administer the medication within 5 cm (2 in) of the umbilicus.
• D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

5. A client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

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