Nursing Elites

1. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a formula with high osmolarity.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hour postprandial.

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

2. What are the key components of a respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Inspection, Observation, Auscultation, Percussion
• C. Auscultation, Palpation, Observation, Percussion
• D. Observation, Palpation, Percussion, Auscultation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for symmetry and signs of distress, palpating for tenderness or abnormal masses, performing percussion to assess underlying tissues, and auscultating lung sounds. Choice B is incorrect as observation is a broad term that can encompass both inspection and palpation. Choice C is incorrect as auscultation is usually performed after inspection and palpation. Choice D is incorrect as observation should be more specific, and auscultation is a key component that is typically done last in a respiratory assessment.

3. A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?

• A. Avoid massaging the site after injection
• B. Massage the site after injection
• C. Use a circular motion to rub the site
• D. Apply a bandage after injecting

Correct answer: A

Rationale: The correct action for the nurse to take after administering an influenza virus immunization by the intradermal route is to avoid massaging the site. Massaging the site can spread the vaccine, potentially reducing its effectiveness. Rubbing the site in a circular motion or applying a bandage are not recommended actions as they can also interfere with the proper absorption of the vaccine.

4. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?

• A. Cross your legs at the knees
• B. Avoid bending your hip more than 90 degrees
• C. Sit with your legs elevated
• D. Avoid placing a pillow under your knees

Correct answer: B

Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.

5. A nurse is caring for a client who is constipated. What intervention is most appropriate?

• A. Administer a laxative to relieve discomfort
• B. Encourage the client to increase dietary fiber intake
• C. Encourage the client to rest until symptoms resolve
• D. Administer a stool softener as prescribed

Correct answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

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