Nursing Elites

1. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

• A. Decreased heart rate
• B. Nausea
• C. Fever
• D. Weight gain

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

2. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

• A. Reassure the client of the surgeon's skill
• B. The surgeon will answer your questions before surgery
• C. Tell the client surgery is necessary
• D. Encourage the client to seek a second opinion

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

3. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Avoid discussing the deceased
• B. Encourage the partner to ask for help when needed
• C. Suggest bereavement counseling
• D. Offer to contact family members

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.

4. A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?

• A. Increase intake of vitamin C
• B. Avoid weight-bearing exercises
• C. Perform weight-bearing exercises
• D. Limit sun exposure

Correct answer: C

Rationale: The correct answer is C: Perform weight-bearing exercises. Weight-bearing exercises help maintain bone density and reduce the risk of osteoporosis in older adults. Choice A, increasing intake of vitamin C, is not directly related to osteoporosis prevention. Choice B, avoiding weight-bearing exercises, is incorrect as weight-bearing exercises are beneficial for bone health. Choice D, limiting sun exposure, is not a key factor in osteoporosis prevention as moderate sun exposure is important for vitamin D synthesis which is essential for bone health.

5. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

Similar Questions