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. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

• A. Confused with cold, clammy skin and a pulse of 110
• B. Lethargic with hot, dry skin and rapid, deep respirations
• C. Alert and cooperative with a BP of 130/80 and respirations of 12
• D. Short of breath, with distended neck veins and a bounding pulse of 96

Correct answer: A

Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.

3. A nurse is reviewing the medical record of a client who is taking furosemide. Which of the following findings should the nurse report to the provider?

• A. Potassium level of 3.8 mEq/L
• B. Sodium level of 135 mEq/L
• C. Magnesium level of 1.6 mEq/L
• D. Calcium level of 8.5 mg/dL

Correct answer: C

Rationale: The correct answer is C. A magnesium level of 1.6 mEq/L is within the normal range, but monitoring potassium levels is crucial for clients taking furosemide. Furosemide can cause hypokalemia (low potassium levels), which can lead to adverse effects such as cardiac dysrhythmias. Sodium and calcium levels are not typically affected by furosemide, so they are not the priority findings to report to the provider in this case.

4. A client receiving chemotherapy is experiencing fatigue. Which intervention should the nurse implement to manage the client's fatigue?

• A. Encourage the client to take short naps during the day
• B. Instruct the client to remain on bedrest
• C. Provide the client with a high-calorie diet
• D. Encourage the client to increase activity levels

Correct answer: A

Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (Choice B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (Choice C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (Choice D) may exacerbate fatigue instead of alleviating it.

5. How should a healthcare provider manage a patient with pneumonia?

• A. Administer antibiotics and provide oxygen therapy
• B. Provide bronchodilators and encourage deep breathing
• C. Administer fluids and encourage bed rest
• D. Monitor for chest pain and provide pain relief

Correct answer: A

Rationale: Correct answer: Administering antibiotics and providing oxygen therapy are essential in managing pneumonia. Antibiotics help treat the infection caused by bacteria, while oxygen therapy improves lung function. Choice B is incorrect because bronchodilators may not be the primary treatment for pneumonia. Choice C is not the priority in pneumonia management, although fluids and rest are important for recovery. Choice D is also not a primary intervention in pneumonia management.

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