Nursing Elites

1. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

• A. Measure the client’s gastric residual every 12 hr.
• B. Obtain the client’s electrolyte levels every 4 hr.
• C. Keep the client’s head elevated at 15* during feedings.
• D. Flush the client’s tube with 30 mL of water every 4 hr.

Correct answer: D

Rationale: Flushing the client's tube with 30 mL of water every 4 hours helps maintain tube patency and prevent blockages.

2. A nurse is on a med-surg unit caring for a client who follows the dietary laws of Orthodox Judaism. Which of the following menu selections should the nurse recommend for this client?

• A. Fried catfish
• B. Broiled shrimp
• C. Pork sausage
• D. Grilled vegetables

Correct answer: D

Rationale: Grilled vegetables comply with the dietary laws of Orthodox Judaism, which restrict the consumption of certain animals.

3. A nurse is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the nurse that the client is experiencing Fluid Volume Deficit?

• A. Hct 53%
• B. Potassium 3.5
• C. Sodium 145
• D. HbA1c 5

Correct answer: A

Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit.

4. A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

• A. Encourage the client to participate in developing a system of rewards.
• B. Arrange for someone to remain with the client for 30 min after meals
• C. Offer the client a selection of beverages at each meal.
• D. Inform the client that a weight gain of 2.3 kg per week is expected.

Correct answer: A

Rationale: Encouraging the client to participate in developing a system of rewards can help motivate and engage them in their treatment plan.

5. A nurse is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?

• A. BUN 8 mg/dL
• B. Hgb 15 g/dL
• C. Creatinine 0.8 mg/dL
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: A BUN level of 8 mg/dL is indicative of fluid volume excess, which is common in clients with heart failure.

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