Nursing Elites

1. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

2. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

3. A client with a nasogastric tube receiving intermittent enteral feedings should be positioned in which way?

• A. Flush the tube with 15 mL of sterile water before feedings.
• B. Place the client in a supine position during feedings.
• C. Position the client with the head of the bed elevated 45 degrees.
• D. Check gastric residuals every 8 hours.

Correct answer: C

Rationale: Positioning the client with the head of the bed elevated at 45 degrees is crucial during enteral feedings to prevent aspiration. This position helps reduce the risk of regurgitation and aspiration of feedings into the lungs. Option A is not necessary before feedings. Placing the client in a supine position (Option B) increases the risk of aspiration. Checking gastric residuals every 8 hours (Option D) is important but not directly related to positioning during enteral feedings.

4. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

5. A client who has a new prescription for spironolactone is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid foods that are high in potassium.
• B. I will avoid foods that are high in sodium.
• C. I will need to have my blood pressure checked regularly while taking this medication.
• D. I will need to have my potassium levels checked regularly while taking this medication.

Correct answer: D

Rationale: The correct answer is D because clients taking spironolactone should have their potassium levels checked regularly. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if levels become too high. Choices A, B, and C are incorrect because avoiding foods high in potassium, sodium, or monitoring blood pressure are not specific to the teaching related to spironolactone.

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