Nursing Elites

1. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

2. A nurse is reviewing the prescription for doxazosin with a client. Which of the following should be included in the teaching?

• A. Decrease caloric intake to prevent weight gain.
• B. Increase dietary fiber to alleviate constipation.
• C. Rise slowly when sitting up from bed.
• D. Take this medication in the morning.

Correct answer: C

Rationale: The correct answer is C. Doxazosin can cause orthostatic hypotension, leading to dizziness and falls if the client rises quickly from a seated position. Instructing the client to rise slowly when sitting up from bed helps prevent these adverse effects. Choices A, B, and D are incorrect because doxazosin does not directly relate to caloric intake, dietary fiber, or a specific time of day for administration.

3. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Abdominal cramps
• B. Irritability
• C. Increased thirst
• D. Blurred vision

Correct answer: B

Rationale: Irritability is a common early manifestation of hypoglycemia. When blood glucose levels drop, the brain perceives this as a stressor, leading to irritability. Abdominal cramps (choice A) are not typically associated with hypoglycemia but can occur with other gastrointestinal issues. Increased thirst (choice C) is more indicative of hyperglycemia rather than hypoglycemia. Blurred vision (choice D) is a symptom more commonly associated with hyperglycemia rather than hypoglycemia.

4. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Apply a dry dressing.
• B. Cleanse the wound with normal saline.
• C. Perform debridement as needed.
• D. Apply a hydrocolloid dressing.

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

5. A nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?

• A. Metoclopramide
• B. Lorazepam
• C. Haloperidol
• D. Methadone

Correct answer: B

Rationale: Lorazepam is the correct medication to administer in this situation. It is used to manage the symptoms of alcohol withdrawal and prevent complications like seizures and delirium tremens. Metoclopramide is primarily used to treat gastrointestinal issues, Haloperidol is an antipsychotic medication used for conditions like schizophrenia, and Methadone is typically used in managing opioid dependence. These medications are not the first-line treatment for alcohol withdrawal.

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