Nursing Elites

1. A nurse is monitoring a client who is receiving continuous enteral feedings. What is a sign of intolerance to the feeding?

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

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain (Choice A) is not typically a sign of intolerance to enteral feedings but may indicate other health issues. Constipation (Choice C) is not a common sign of feeding intolerance. Decreased heart rate (Choice D) is not typically associated with intolerance to enteral feedings.

2. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?

• A. Apply a warm compress
• B. Discontinue the IV line
• C. Increase the IV flow rate
• D. Elevate the limb

Correct answer: B

Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.

3. A client expresses anxiety about an upcoming surgery. What should the nurse do?

• A. Administer a sedative
• B. Ask the client to describe their feelings
• C. Call the surgeon to address the anxiety
• D. Provide information on post-op care

Correct answer: B

Rationale: When a client expresses anxiety, it is essential for the nurse to encourage the client to verbalize their feelings. This helps the client express concerns, fears, and uncertainties, enabling the nurse to provide appropriate emotional support. Administering a sedative (Choice A) should not be the initial response as it does not address the underlying emotional needs of the client. Calling the surgeon to address anxiety (Choice C) may not be within the nurse's scope of practice and may not directly address the client's emotional needs. Providing information on post-op care (Choice D) is important but not the priority when the client is experiencing anxiety preoperatively.

4. A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?

• A. Administer the medication with a straw
• B. Flush the NG tube with 30 mL of water before administration
• C. Crush all medications together
• D. Mix the medication with pudding

Correct answer: B

Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.

5. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?

• A. Dissolve crushed tablet medications in tap water
• B. Administer all medications together
• C. Flush the NG tube with 60 mL of water before each medication
• D. Dissolve medications separately and flush with sterile water

Correct answer: D

Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.

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