Nursing Elites

1. What action is required by law when preparing to administer a controlled substance?

• A. Verify the client’s identification using two identifiers.
• B. Document the medication administration in the client’s chart immediately.
• C. Return any unused portion of the medication to the pharmacy.
• D. Have a second nurse witness the disposal of any unused portion.

Correct answer: D

Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.

2. A client with a new diagnosis of hypertension is being taught about lifestyle changes. Which of the following statements should the nurse include in the teaching?

• A. You should limit your alcohol intake to no more than one drink per day.
• B. You should increase your sodium intake to at least 2,300 mg per day.
• C. You should limit your physical activity to avoid increasing your blood pressure.
• D. You should avoid eating dairy products to help lower your blood pressure.

Correct answer: A

Rationale: The correct statement to include in teaching a client with hypertension is to limit alcohol intake to no more than one drink per day. Excessive alcohol consumption can raise blood pressure and lead to complications. Increasing sodium intake, limiting physical activity, and avoiding dairy products are not recommended for managing hypertension. Clients with hypertension should follow a heart-healthy diet low in sodium, engage in regular physical activity, and monitor their blood pressure regularly to control hypertension effectively.

3. A client with a seizure disorder is under the care of a nurse. Which of the following precautions should the nurse include in the plan?

• A. Place a padded tongue depressor at the bedside.
• B. Keep the bed in the lowest position.
• C. Restrain the client during a seizure.
• D. Keep the lights dim in the client's room.

Correct answer: B

Rationale: Keeping the bed in the lowest position is crucial for ensuring the safety of the client during a seizure. Lowering the bed reduces the risk of injury if the client falls during a seizure episode. It is important not to restrain the client during a seizure as it can lead to further injury. Placing a padded tongue depressor at the bedside is not appropriate and can pose a risk of injury if used incorrectly. Keeping the lights dim in the client's room is not directly related to safety during a seizure and is not a standard precaution.

4. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

5. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

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